ohiocontract.htm


    
      Back to Form 8-K

      Exhibit 10.1

      Baseline

      Covered
Families and Children (CFC) Population

      
 

      OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES

      


      OHIO
MEDICAL ASSISTANCE PROVIDER AGREEMENT

      FOR
MANAGED CARE PLAN

      CFC
ELIGIBLE POPULATION

      


      This provider agreement is entered into
this first day of July, 2008, at Columbus, Franklin County, Ohio, between the
State of Ohio, Department of Job and Family Services, (hereinafter referred to
as ODJFS) whose principal offices are located in the City of Columbus, County of
Franklin, State of Ohio, and WellCare of Ohio, Inc, Managed Care Plan
(hereinafter referred to as MCP), an Ohio for-profit corporation, whose
principal office is located in the city of Independence, County of Cuyahoga,
State of Ohio.

      


      MCP is licensed as a Health Insuring
Corporation by the State of Ohio, Department of Insurance (hereinafter referred
to as ODI), pursuant to Chapter 1751. of the Ohio Revised Code and is organized
and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio
Administrative Code (hereinafter referred to as OAC), and other applicable
portions of the OAC as amended from time to time.

      


      MCP is an entity eligible to enter into
a provider agreement in accordance with 42 CFR 438.6 and is engaged in the
business of providing prepaid comprehensive health care services as defined in
42 CFR 438.2 through the managed care program for the Covered Families and
Children (CFC) eligible population described in OAC rule 5101:3-26-02
(B).

      


      ODJFS, as the single state agency
designated to administer the Medicaid program under Section 5111.02 of the Ohio
Revised Code and Title XIX of the Social Security Act, desires to obtain MCP
services for the benefit of certain Medicaid recipients.  In so doing,
MCP has provided and will continue to provide proof of MCP's capability to
provide quality services, efficiently, effectively and economically during the
term of this agreement.

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

           

                     
This provider agreement is a contract between ODJFS and the undersigned Managed
Care Plan (MCP), provider of medical assistance, pursuant to the federal
contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP agrees to
provide comprehensive medical services through the managed care program as
provided in Chapter 5101:3-26 of the Ohio Administrative Code, assuming the risk
of loss, and complying with applicable state statutes, Ohio Administrative Code,
and Federal statutes,  rules, regulations and other requirements,
including but not limited to title VI of the Civil Rights Act of 1964; title IX
of the Education Amendments of 1972 (regarding education programs and
activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973;
and the Americans with Disabilities Act.

       

      ARTICLE
I  -  GENERAL

      


      
        	
                A.

              	
                ODJFS
      enters into this Agreement in reliance upon MCP’s representations that it
      has the necessary expertise and experience to perform its obligations
      hereunder, and MCP warrants that it does possess the necessary expertise
      and experience.

              


      

      


      
        	
                B.

              	
                MCP
      agrees to report to the Chief of Bureau of Managed Health Care
      (hereinafter referred to as BMHC) or his or her designee as necessary to
      assure understanding of the responsibilities and satisfactory compliance
      with this provider agreement.

              


      

      


      
        	
                C.

              	
                MCP
      agrees to furnish its support staff and services as necessary for the
      satisfactory performance of the services as enumerated in this provider
      agreement.

              


      

      


      
        	
                D.

              	
                ODJFS
      may, from time to time as it deems appropriate, communicate specific
      instructions and requests to MCP concerning the performance of the
      services described in this provider agreement.  Upon such notice
      and within the designated time frame after receipt of instructions, MCP
      shall comply with such instructions and fulfill such requests to the
      satisfaction of the department.  It is expressly understood by
      the parties that these instructions and requests are for the sole purpose
      of performing the specific tasks requested to ensure satisfactory
      completion of the services described in this provider agreement, and are
      not intended to amend or alter this provider agreement or any part
      thereof.

              


      

       

      
        	
                E.

              	
                If
      the MCP previously had a provider agreement with the ODJFS and the
      provider agreement terminated more than two years prior to the effective
      date of any new provider agreement, such MCP will be considered a new plan
      in its first year of operation with the Ohio Medicaid managed care
      program.

              


      

       

      ARTICLE
II  -  TIME OF PERFORMANCE

      


      
        	
                A.

              	
                Upon
      approval by the Director of ODJFS this provider agreement shall be in
      effect from the date entered through June 30, 2009, unless this provider
      agreement is suspended or terminated pursuant to Article VIII prior to the
      termination date, or otherwise amended pursuant to Article
    IX.

              


      

      


      
        	
                B.

              	
                It
      is expressly agreed by the parties that none of the rights, duties and
      obligations herein shall be binding on either party if award of this
      Agreement would be contrary to the terms of Ohio Revised Code (“O.R.C.”)
      Section 3517.13, O.R.C. Section 127.16, or O.R.C. Chapter
    102.

              


      

       

      
        
          
            
            

          

          
            2

            
              

            

          

          
            
              Baseline

              Covered
Families and Children (CFC) Population

            

          

        

         

        ARTICLE
III  -  REIMBURSEMENT

      

      


      
        	
                A.

              	
                ODJFS
      will reimburse MCP in accordance with rule 5101:3-26-09 of the Ohio
      Administrative Code and the appropriate appendices of this provider
      agreement.

              


      

      


      ARTICLE
IV  -  RELATIONSHIP OF PARTIES

      


      
        	
                A.

              	
                ODJFS
      and MCP agree that, during the term of this Agreement, MCP shall be
      engaged by ODJFS solely on an independent contractor basis, and neither
      MCP nor its personnel shall, at any time or for any purpose, be considered
      as agents, servants or employees of ODJFS or the State of Ohio. MCP
      shall therefore be responsible for all MCP’s business expenses, including,
      but not limited to, employee’s wages and salaries, insurance of every type
      and description, and all business and personal taxes, including income and
      Social Security taxes and contributions for Workers’ Compensation and
      Unemployment Compensation coverage, if
any.

              


      

      


      
        	
                B.

              	
                MCP
      agrees to comply with all applicable federal, state and local laws in the
      conduct of the work hereunder.

              


      

      


      
        	
                C.

              	
                While
      MCP shall be required to render services described hereunder for ODJFS
      during the term of this Agreement, nothing herein shall be construed to
      imply, by reason of MCP’s engagement hereunder on an independent
      contractor basis, that ODJFS shall have or may exercise any right of
      control over MCP with regard to the manner or method of MCP’s performance
      of services hereunder. The management of the work, including the
      exclusive right to control or direct the manner or means by which the
      work is performed, remains with MCP.  ODJFS retains the
      right to ensure that MCP's work is in conformity with the terms and
      conditions of this Agreement.

              


      

       

      
        	
                D.

              	
                Except
      as expressly provided herein, neither party shall have the right to bind
      or obligate the other party in any manner without the  other
      party’s prior written consent.

              


      

       

      
        ARTICLE
V  -  CONFLICT OF INTEREST; ETHICS LAWS

      

      


      
        	
                A.

              	
                In
      accordance with the safeguards specified in section 27 of the Office of
      Federal Procurement Policy Act (41 U.S.C. 423) and other applicable
      federal requirements, no officer, member or employee of MCP, the Chief of
      BMHC, or other ODJFS employee who exercises any functions or
      responsibilities in connection with the review or approval of this
      provider agreement or provision of services under this provider agreement
      shall, prior to the completion of such services or reimbursement, acquire
      any interest, personal or otherwise, direct or indirect, which is
      incompatible or in conflict with, or would compromise in any manner or
      degree the discharge and fulfillment of his or her functions and
      responsibilities with respect to the carrying out of such
      services.  For purposes of this article,
      "members" does not include individuals whose sole connection with MCP is
      the receipt of services through a health care program offered by
      MCP.

              


      

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      
        	
                B.

              	
                MCP
      represents, warrants, and certifies that it and its employees engaged in
      the administration or performance of this Agreement are knowledgeable of
      and understand the Ohio Ethics and Conflicts of Interest laws and
      Executive Order 2007-01S.  MCP further represents, warrants, and
      certifies that neither MCP nor any of its employees will do any act that
      is inconsistent with such laws and Executive Order.  The
      Governor’s Executive Orders may be found by accessing the following
      website:  http://governor.ohio.gov/GovernorsOffice/ExecutiveOrdersDirectives/tabid/105/Default.aspx.

              


      

       

      
        	
                C.

              	
                MCP
      hereby covenants that MCP, its officers, members and employees of the MCP,
      shall not, prior to the completion of the work under this Agreement,
      voluntarily acquire any interest, personal or otherwise, direct or
      indirect, which is incompatible or in conflict with or would compromise in
      any manner of degree  the discharge and fulfillment of his or
      her functions and responsibilities under this provider
      agreement.  MCP shall periodically inquire of its officers,
      members and employees concerning such
interests.

              


      

      


      
        	
                D.

              	
                Any
      such person who acquires an incompatible, compromising or conflicting
      personal or business interest, on or after the effective date of this
      Agreement, or who involuntarily acquires any such incompatible or
      conflicting personal interest, shall immediately disclose his or her
      interest to ODJFS in writing.  Thereafter, he or she shall not
      participate in any action affecting the services under this provider
      agreement, unless ODJFS shall determine in its sole discretion that, in
      the light of the personal interest disclosed, his or her participation in
      any such action would not be contrary to the public
      interest.  The written disclosure of such interest shall be made
      to:  Chief, Bureau of Managed Health Care,
  ODJFS.

              


      

       

      
        	
                E.

              	
                No
      officer, member or employee of MCP shall promise or give to any ODJFS
      employee anything of value that is of such a character as to manifest a
      substantial and improper influence upon the employee with respect to his
      or her duties.  No officer, member or employee of MCP shall
      solicit an ODJFS employee to violate any ODJFS rule or policy relating to
      the conduct of the parties to this agreement or to violate sections
      102.03, 102.04, 2921.42 or 2921.43 of the Ohio Revised
    Code.

              


      

      


      
        	
                F.

              	
                MCP
      hereby covenants that MCP, its officers, members and employees are in
      compliance with section 102.04 of the Revised Code and that if MCP is
      required to file a statement pursuant to 102.04(D)(2) of the Revised Code,
      such statement has been filed with the ODJFS in addition to any other
      required filings.

              


      

       

      ARTICLE
VI  -  NONDISCRIMINATION OF EMPLOYMENT

      


      
        	
                A.

              	
                MCP
      agrees that in the performance of this provider agreement or in the hiring
      of any employees for the performance of services under this provider
      agreement, MCP shall not by reason of race, color, religion, gender,
      sexual orientation, age, disability, national origin, veteran's status,
      health status, or ancestry, discriminate against any citizen of this state
      in the employment of a person qualified and available to perform the
      services to which the provider agreement
  relates.

              


      

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      
        	
                B.

              	
                MCP
      agrees that it shall not, in any manner, discriminate against, intimidate,
      or retaliate against any employee hired for the performance or services
      under the provider agreement on account of race, color, religion, gender,
      sexual orientation, age, disability, national origin, veteran's status,
      health status, or ancestry.

              


      

      


      
        	
                C.

              	
                In
      addition to requirements imposed upon subcontractors in accordance with
      OAC Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons
      acting on behalf of MCP in the performance of services under this provider
      agreement responsible for adhering to the requirements of paragraphs (A)
      and (B) above and shall include the requirements of paragraphs (A) and (B)
      above in all subcontracts for services performed under this provider
      agreement, in accordance with rule 5101:3-26-05 of the Ohio Administrative
      Code.

              


      

       

      ARTICLE
VII  -  RECORDS, DOCUMENTS AND INFORMATION

      


      
        	
                A.

              	
                MCP
      agrees that all records, documents, writings or other information produced
      by MCP under this provider agreement and all records, documents, writings
      or other information used by MCP in the performance of this provider
      agreement shall be treated in accordance with rule 5101:3-26-06 of the
      Ohio Administrative Code.  MCP must maintain an appropriate
      record system for services provided to members. MCP must retain all
      records in accordance with 45 CFR Part
74.

              


      

      


      
        	
                B.

              	
                All
      information provided by MCP to ODJFS that is proprietary shall be held to
      be strictly confidential by ODJFS.  Proprietary information is
      information which, if made public, would put MCP at a disadvantage in the
      market place and trade of which MCP is a part [see Ohio Revised Code
      Section 1333.61(D)].  MCP is responsible for notifying ODJFS of
      the nature of the information prior to its release to
      ODJFS.  Failure to provide such prior notification is deemed to
      be a waiver of the proprietary nature of the information, and a waiver of
      any right of MCP to proceed against ODJFS for violation of this agreement
      or of any proprietary or trade secret laws.  Such failure shall
      also be deemed a waiver of trade secret protection in that the MCP will
      have failed to make efforts that are reasonable under the circumstances to
      maintain the information’s secrecy. ODJFS reserves the right to require
      reasonable evidence of MCP's assertion of the proprietary nature of any
      information to be provided and ODJFS will make the final determination of
      whether any or all of the information identified by the MCP is proprietary
      or a trade secret.  The provisions of this Article are not
      self-executing.

              


      

      


      
        	
                C.

              	
                MCP
      shall not use any information, systems, or records made available to it
      for any purpose other than to fulfill the duties specified in this
      provider agreement.  MCP agrees to be bound by the same
      standards of confidentiality that apply to the employees of the ODJFS and
      the State of Ohio.  The terms of this section shall be included
      in any subcontracts executed by MCP for services under this provider
      agreement.  MCP must implement procedures to ensure that in the
      process of coordinating care, each enrollee's privacy is protected
      consistent with the confidentiality requirements in 45 CFR parts 160 and
      164.

              


      

    

     

    
      
        
        

      

      
        5

        
          

        

      

      
        
          Baseline

          Covered
Families and Children (CFC) Population

        

      

    

     

    
      ARTICLE
VIII  -  SUSPENSION AND TERMINATION

      


      
        	
                A.

              	
                This
      provider agreement may be suspended or terminated by the department or MCP
      upon written notice in accordance with the applicable rule(s) of the Ohio
      Administrative Code, with termination to occur at the end of the last day
      of a month.

              


      

      


      
        	
                B.

              	
                MCP,
      upon receipt of notice of suspension or termination, shall cease provision
      of services on the suspended or terminated activities under this provider
      agreement; suspend, or terminate all subcontracts relating to such
      suspended or terminated activities, take all necessary or appropriate
      steps to limit disbursements and minimize costs, and furnish a report, as
      of the date of receipt of notice of suspension or termination describing
      the status of all services under this provider
  agreement.

              


      

      


      
        	
                C.

              	
                In
      the event of suspension or termination under this Article, MCP shall be
      entitled to reconciliation of reimbursements through the end of the month
      for which services were provided under this provider agreement, in
      accordance with the reimbursement provisions of this provider
      agreement.  MCP agrees to waive any right to, and shall make no
      claim for, additional compensation against ODJFS by reason of such
      suspension or termination.

              


      

      


      
        	
                D.

              	
                ODJFS
      may, in its judgment, suspend, terminate or fail to renew this provider
      agreement if the MCP or MCP's subcontractors violate or fail to comply
      with the provisions of this agreement or other provisions of law or
      regulation governing the Medicaid program.  Where ODJFS proposes
      to suspend, terminate or refuse to enter into a provider agreement, the
      provisions of applicable sections of the Ohio Administrative Code with
      respect to ODJFS' suspension, termination or refusal to enter into a
      provider agreement shall apply, including the MCP's right to request an
      adjudication hearing under Chapter 119. of the Revised
    Code.

              


      

      


      
        	
                E.

              	
                When
      initiated by MCP, termination of or failure to renew the provider
      agreement requires written notice to be received by ODJFS at least 120
      days in advance of the termination or renewal date, provided, however,
      that termination or non-renewal must be effective at the end of the last
      day of a calendar month.  In the event of non-renewal of the
      provider agreement with ODJFS, if MCP is unable to provide notice to ODJFS
      120 days prior to the date when the provider agreement expires, and if, as
      a result of said lack of notice, ODJFS is unable to disenroll Medicaid
      enrollees prior to the expiration date, then the provider agreement shall
      be deemed extended for up to four calendar months beyond the expiration
      date and both parties shall, for that time, continue to fulfill their
      duties and obligations as set forth herein. If an MCP wishes to terminate
      or not renew their provider agreement for a specific region(s), ODJFS
      reserves the right to initiate a procurement process to select
      additional MCPs to serve Medicaid consumers in that region(s). ODJFS,
      at its discretion, may use an MCP’s termination or non-renewal of
      this provider agreement as a factor in any future procurement
      process.

              


      

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      ARTICLE
IX  -  AMENDMENT AND RENEWAL

      


      
        	
                A.

              	
                This
      writing constitutes the entire agreement between the parties with respect
      to all matters herein.  This provider agreement may be amended
      only by a writing signed by both parties.  Any written
      amendments to this provider agreement shall be prospective in
      nature.

              


      

      


      
        	
                B.

              	
                This
      provider agreement may be renewed one or more times by a writing signed by
      both parties for a period of not more than twelve months for each
      renewal.

              


      

      


      
        	
                C.

              	
                In
      the event that changes in State or Federal law, regulations, an applicable
      waiver or state plan amendment, or the terms and conditions of any
      applicable federal waiver or state plan amendment, require ODJFS to modify
      this agreement, ODJFS shall notify MCP regarding such changes and this
      agreement shall be automatically amended to conform to such changes
      without the necessity for executing written amendments pursuant to this
      Article of this provider agreement.

              


      

      


      
        	
                D.

              	
                This
      Agreement supersedes any and all previous agreements, whether written or
      oral, between the parties.

              


      

      


      
        	
                E.

              	
                A
      waiver by any party of any breach or default by the other party under this
      Agreement shall not constitute a continuing waiver by such party of any
      subsequent act in breach of or in default
  hereunder.

              


      

       

      ARTICLE
X  -  LIMITATION OF LIABILITY

      


      
        	
                A.

              	
                MCP
      agrees to indemnify and to hold ODJFS and the State of Ohio harmless and
      immune from any and all claims for injury or damages resulting from the
      actions or omissions of MCP or its subcontractors in the fulfillment of
      this provider agreement or arising from this Agreement which are
      attributable to the MCP’s own actions or omissions of those of its
      trustees, officers, employees, subcontractors, suppliers, third parties
      utilized by MCP, or joint venturers while acting under this
      Agreement.  Such claims shall include any claims made under the
      Fair Labor Standards Act or under any other federal or state law involving
      wages, overtime, or employment matters and any claims involving patents,
      copyrights, and trademarks.  MCP shall bear all costs associated
      with defending ODJFS and the State of Ohio against these
      claims.

              


      

      


      
        	
                B.

              	
                MCP
      hereby agrees to be liable for any loss of federal funds suffered by ODJFS
      for enrollees resulting from specific, negligent acts or omissions of the
      MCP or its subcontractors during the term of this agreement, including but
      not limited to the nonperformance of the duties and obligations to which
      MCP has agreed under this
agreement.

              


      

       

      
        
          
          

        

        
          7

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      
        	
                C.

              	
                In
      the event that, due to circumstances not reasonably within the control of
      MCP or ODJFS, a major disaster, epidemic, complete or substantial
      destruction of facilities, war, riot or civil insurrection occurs,
      neither ODJFS nor MCP will have any liability or obligation on account of
      reasonable delay in the provision or the arrangement of covered services;
      provided that so long as MCP's certificate of authority remains in full
      force and effect, MCP shall be liable for the covered services required to
      be provided or arranged for in accordance with this
    agreement.

              


      

       

      
        	
                D.

              	
                In
      no event shall either party be liable to the other party for indirect,
      consequential, incidental, special or punitive damages, or lost
      profits.

              


      

       

      ARTICLE
XI - ASSIGNMENT

      


      
        	
                A.

              	
                ODJFS
      will not allow the transfer of Medicaid members by one MCP to another MCP
      unless this membership has been obtained as a result of an MCP selling
      their entire Ohio corporation to another health plan. MCP shall not assign
      any interest in this provider agreement and shall not transfer any
      interest in the same (whether by assignment or novation) without the prior
      written approval of ODJFS and subject to such conditions and provisions as
      ODJFS may deem necessary.  Any such assignments shall be
      submitted for ODJFS’ review 120 days prior to the desired effective
      date.  No such approval by ODJFS of any assignment shall be
      deemed in any event or in any manner to provide for the incurrence of any
      obligation by ODJFS in addition to the total agreed-upon reimbursement in
      accordance with this agreement.

              


      

      


      
        	
                B.

              	
                MCP
      shall not assign any interest in subcontracts of this provider agreement
      and shall not transfer any interest in the same (whether by assignment or
      novation) without the prior written approval of ODJFS and subject to such
      conditions and provisions as ODJFS may deem necessary.  Any such
      assignments of subcontracts shall be submitted for ODJFS’ review 30 days
      prior to the desired effective date.  No such approval by ODJFS
      of any assignment shall be deemed in any event or in any manner to provide
      for the incurrence of any obligation by ODJFS in addition to the total
      agreed-upon reimbursement in accordance with this
    agreement.

              


      

       

      
        ARTICLE
XII  -  CERTIFICATION MADE BY MCP

      

      


      
        	
                A.

              	
                This
      agreement is conditioned upon the full disclosure by MCP to ODJFS of all
      information required for compliance with federal regulations as requested
      by ODJFS.

              


      

      


      
        	
                B.

              	
                By
      executing this agreement, MCP certifies that no federal funds paid to MCP
      through this or any other agreement with ODJFS shall be or have been used
      to lobby Congress or any federal agency in connection with a particular
      contract, grant, cooperative agreement or loan.  MCP further
      certifies compliance with the lobbying restrictions contained in Section
      1352, Title 31 of the U.S. Code, Section 319 of Public Law 101-121 and
      federal regulations issued pursuant thereto and contained in 45 CFR Part
      93, Federal Register, Vol. 55, No. 38, February 26, 1990, pages
      6735-6756.  If this provider agreement exceeds $100,000, MCP has
      executed the Disclosure of Lobbying Activities, Standard Form LLL, if
      required by federal regulations.  This certification is material
      representation of fact upon which reliance was placed when this provider
      agreement was entered into.

              


      

       

      
        
          
          

        

        
          8

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      
        	
                C.

              	
                By
      executing this agreement, MCP certifies that neither MCP nor any
      principals of MCP (i.e., a director, officer, partner, or person with
      beneficial ownership of more than 5% of the MCP’s equity) is presently
      debarred, suspended, proposed for debarment, declared ineligible, or
      otherwise  excluded from participation in transactions by any
      Federal  agency.  The MCP also certifies that it is
      not debarred from consideration for contract awards by the Director of the
      Department of Administrative Services, pursuant to either O.R.C. Section
      153.02 or O.R.C. Section 125.25.  The MCP also certifies that
      the MCP has no employment, consulting or any other arrangement with any
      such debarred or suspended person for the provision of items or services
      or services that are significant and material to the MCP’s contractual
      obligation with ODJFS.  This certification is a material
      representation of fact upon which reliance was placed when this provider
      agreement was entered into. If it is ever determined that MCP knowingly
      executed this certification erroneously, then in addition to any other
      remedies, this provider agreement shall be terminated pursuant to Article
      VII, and ODJFS must advise the Secretary of the appropriate Federal agency
      of the knowingly erroneous
certification.

              


      

       

      
        	
                D.

              	
                By
      executing this agreement, MCP certifies compliance with Article V as well
      as agreeing to future compliance with Article V.  This
      certification is a material representation of fact upon which reliance was
      placed when this contract was entered
into.

              


      

       

      
        	
                E.

              	
                By
      executing this agreement, MCP certifies compliance with the executive
      agency lobbying requirements of sections 121.60 to 121.69 of the Ohio
      Revised Code. This certification is a material representation of fact upon
      which reliance was placed when this provider agreement was entered
      into.

              


      

      


      
        	
                F.

              	
                By
      executing this agreement, MCP certifies that MCP is not on the most recent
      list established by the Secretary of State, pursuant to section 121.23 of
      the Ohio Revised Code, which identifies MCP as having more than one unfair
      labor practice contempt of court finding.  This certification is
      a material representation of fact upon which reliance was placed when this
      provider agreement was entered
into.

              


      

       

      
        	
                G.

              	
                By
      executing this agreement MCP agrees not to discriminate against
      individuals who have or are participating in any work program administered
      by a county Department of Job and Family Services under Chapters 5101 or
      5107 of the Revised Code.

              


      

      


      
        	
                H.

              	
                By
      executing this agreement, MCP certifies and affirms that, as applicable to
      MCP, that no party listed or described in Division (I) or (J) of Section
      3517.13 of the Ohio Revised Code who was actually in a listed position at
      the time of the contribution, has made as an individual, within the two
      previous calendar years, one or more contributions in excess of One
      Thousand and 00/100 ($1,000.00) to the present Governor or to the
      governor’s campaign committees during any time he/she was a candidate for
      office.  This certification is a material representation of fact
      upon which reliance was placed when this provider agreement was entered
      into.  If it is ever determined that MCP's certification of this
      requirement is false or misleading, and not withstanding any criminal or
      civil liabilities imposed by law, MCP shall return to ODJFS all
      monies paid to MCP under this provider agreement.  The
      provisions of this section shall survive the expiration or termination of
      this provider agreement.

              


      

       

      
        
          
          

        

        
          9

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      
        	
                I.

              	
                MCP
      agrees to refrain from promising or giving to any ODJFS employee anything
      of value that is of such a character as to manifest a substantial and
      improper influence upon the employee with respect to his or her
      duties.  MCP also agrees that it will not solicit an ODJFS
      employee to violate any ODJFS rule or policy relating to the conduct of
      contracting parties or to violate sections 102.03, 102.04, 2921.42 or
      2921.43 of the Ohio Revised Code.

              


      

      


      
        	
                J.

              	
                By
      executing this agreement, MCP certifies and affirms that HHS, US
      Comptroller General or representatives will have access to books,
      documents, etc. of MCP.

              


      

      


      
        	
                K.

              	
                By
      executing this agreement, MCP agrees to comply with the false claims
      recovery requirements of Section 6032 of The Deficit Reduction Act of 2005
      (also see Section 5111.101 of the Revised
  Code).

              


      

       

      
        	
                L.

              	
                MCP,
      its officers, employees, members, any subcontractors, and/or any
      independent contractors (including all field staff) associated with this
      agreement agree to comply with all applicable state and federal laws
      regarding a smoke-free and drug-free workplace.  The MCP will
      make a good faith effort to ensure that all MCP officers, employees,
      members, and subcontractors will not purchase, transfer, use or possess
      illegal drugs or alcohol, or abuse prescription drugs in any way while
      performing their duties under this
Agreement.

              


      

      


      
        	
                M.

              	
                MCP
      hereby represents and warrants to ODJFS that it has not provided any
      material assistance, as that term is defined in O.R.C. Section 2909.33(C),
      to any organization identified by and included on the United States
      Department of State Terrorist Exclusion List and that it has
      truthfully answered “no” to every question on the
      “Declaration Regarding Material Assistance/Non-assistance to a
      Terrorist Organization.”  MCP further represents and warrants
      that it has provided or will provide such to ODJFS prior to execution of
      this Agreement.  If these representations and warranties are
      found to be false, this Agreement is void ab initio and MCP shall
      immediately repay to ODJFS any funds paid under this
      Agreement.

              


      

       

      
        ARTICLE
XIII - CONSTRUCTION

      

      


      
        	
                A.

              	
                This
      provider agreement shall be governed, construed and enforced in accordance
      with the laws and regulations of the State of Ohio and appropriate federal
      statutes and regulations.  The provisions of this Agreement are
      severable and independent, and if any such provision shall be determined
      to be unenforceable, in whole or in part, the remaining provisions and any
      partially enforceable provision shall, to the extent enforceable in any
      jurisdiction, nevertheless be binding and
  enforceable.

              


      

       

      
        
          
          

        

        
          10

          
            

          

        

        
          
            Baseline

            Covered
Families and Children (CFC) Population

          

        

      

       

      ARTICLE
XIV - INCORPORATION BY REFERENCE

      


      
        	
                A.

              	
                Ohio
      Administrative Code Chapter 5101:3-26 (Appendix A) is hereby incorporated
      by reference as part of this provider agreement having the full force and
      effect as if specifically restated
herein.

              


      

       

      
        	
                B.

              	
                Appendices
      B through P and any additional appendices are hereby incorporated by
      reference as part of this provider agreement having the full force and
      effect as if specifically restated
herein.

              


      

      


      
        	
                C.

              	
                In
      the event of inconsistence or ambiguity between the provisions of OAC
      Chapter 5101:3-26 and this provider agreement, the provisions of OAC
      Chapter 5101:3-26 shall be determinative of the obligations of the parties
      unless such inconsistency or ambiguity is the result of changes in federal
      or state law, as provided in Article IX of this provider agreement, in
      which case such federal or state law shall be determinative of the
      obligations of the parties.  In the event OAC 5101:3-26 is
      silent with respect to any ambiguity or inconsistency, the provider
      agreement (including Appendices B through P and any additional
      appendices), shall be determinative of the obligations of the
      parties.  In the event that a dispute arises which is not
      addressed in any of the aforementioned documents, the parties agree to
      make every reasonable effort to resolve the dispute, in keeping with the
      objectives of the provider agreement and the budgetary and statutory
      constraints of ODJFS.

              


      

      


      ARTICLE
XV – NOTICES

      


      All
notices, consents, and communications hereunder shall be given in writing, shall
be deemed to be given upon receipt thereof, and shall be sent to the addresses
first set forth above.

      


      ARTICLE
XVI – HEADINGS

      


      The
headings in this Agreement have been inserted for convenient reference only and
shall not be considered in any questions of interpretation or construction of
this Agreement.

       

      
        
          
             


          

          
            11

            
              

            

          

          
            
              Baseline

              Covered
Families and Children (CFC) Population

            

          

        

      

      


      The
parties have executed this agreement the date first written
above.  The agreement is hereby accepted and considered binding in
accordance with the terms and conditions set forth in the preceding
statements.

      


      WELLCARE
OF OHIO, INC.:

      


      


      


      
        	
                BY:  /s/ Heath
      Schiesser                                                                  

              	
                DATE:
      6/23/08

              
	
                        HEATH
      SCHIESSER, CHIEF EXECUTIVE OFFICER AND PRESIDENT

                        

              	 
      


      

      


      


      


      OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:

      


      


      


      
        	
                BY:  /s/
      Helen Jones-Kelly

              	
                DATE:
      6/30/08

              
	
                        HELEN
      E. JONES-KELLY, DIRECTOR

              	 
      


      

      


      
        
          
             


          

          
            12

            
              

            

          

          
             


          

        

      

      


      CFC PROVIDER AGREEMENT
INDEX

       July 1,
2008

      


          APPENDIX                                                        TITLE

      


          APPENDIX
A                                                    OAC
RULES 5101:3-26

      


      
        	
                    APPENDIX
      B

              	
                SERVICE
      AREA SPECIFICATIONS – CFC ELIGIBLE
POPULATION

              


      

      


          APPENDIX
C                                             
       MCP RESPONSIBILITIES – CFC ELIGIBLE
POPULATION

       

      
        	
                    APPENDIX
      D

              	
                ODJFS
      RESPONSIBILITIES – CFC
  ELIGIBLE  POPULATION

              


      

      


          APPENDIX
E                                                     RATE
METHODOLOGY – CFC ELIGIBLE POPULATION

      


          APPENDIX
F                                                     REGIONAL
RATES – CFC ELIGIBLE  POPULATION

      


      
        	
                    APPENDIX
      G

              	
                COVERAGE
      AND SERVICES – CFC ELIGIBLE
POPULATION

              


      

      


      
        	
                    APPENDIX
      H

              	
                PROVIDER
      PANEL SPECIFICATIONS – CFC ELIGIBLE
POPULATION

              


      

      


          APPENDIX
I                                            
         PROGRAM INTEGRITY– CFC
ELIGIBLE POPULATION

      


      
        	
                    APPENDIX
      J

              	
                FINANCIAL
      PERFORMANCE – CFC ELIGIBLE
POPULATION

              


      

      


      
        	
                    APPENDIX
      K

              	
                QUALITY
      ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM – CFC ELIGIBLE
      POPULATION

              


      

      


          APPENDIX
L                                                     DATA
QUALITY – CFC ELIGIBLE POPULATION

      


      
        	
                    APPENDIX
      M

              	
                PERFORMANCE
      EVALUATION – CFC ELIGIBLE
POPULATION

              


      

      


      
        	
                    APPENDIX
      N

              	
                COMPLIANCE
      ASSESSMENT SYSTEM – CFC ELIGIBLE
POPULATION

              


      

      


      
        	
                    APPENDIX
      O

              	
                PAY-FOR-PERFORMANCE
      (P4P) – CFC ELIGIBLE POPULATION

              


      

       

      
        	
                    APPENDIX
      P

              	
                MCP
      TERMINATIONS/NONRENEWALS/AMENDMENTS – CFC ELIGIBLE
    POPULATION

              


      

      


      
        
          
             


          

          
             


            
              

            

          

          
            
              Appendix
A

              Covered
Families and Children (CFC) Population 


            

          

        

      

      


      APPENDIX
A

      


      OAC
RULES 5101:3-26

      


      The
managed care program rules can be accessed electronically through the BMHC
page of the ODJFS website.

       

      
        
          
             


          

          
            1

            
              

            

          

          
            
              Appendix
B

              Covered
Families and Children (CFC) Population 


            

          

        

      

      


      APPENDIX
B

      


      SERVICE AREA
SPECIFICATIONS

      CFC
ELIGIBLE POPULATION

      


      MCP
: WELLCARE OF OHIO, INC.

      


      The MCP agrees to provide
services to Covered Families and Children (CFC) members  residing in
the following service area(s):

      


      Service Area: Northeast
Region – Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, and
Medina counties.

       

      
        
          
             


          

          
            1

            
              

            

          

          
            
              
                Appendix
C 

                Covered
Families and Children (CFC)
population

              

            

          

        

      

       

      
        APPENDIX
C

        


        MCP
RESPONSIBILITIES

        CFC
ELIGIBLE POPULATION

        


        The MCP
must meet on an ongoing basis, all program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of Job
and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but are required by
ODJFS.

        


        General
Provisions

        


        
          	
                  1. 

                	
                  The
      MCP agrees to implement program modifications as soon as reasonably
      possible or no later than the required effective date, in response to
      changes in applicable state and federal laws and
    regulations.

                


        

        


        
          	
                  2.  

                	
                  The
      MCP must submit a current copy of their Certificate of Authority (COA) to
      ODJFS within 30 days of issuance by the Ohio Department of
      Insurance.

                


        

        


        
          	
                  3.

                	
                  The
      MCP must designate the following:

                


        

        


        
          	
                   

                	a.
      	
                  A
      primary contact person (the Medicaid Coordinator) who will dedicate a
      majority of their time to the Medicaid product line and coordinate overall
      communication between ODJFS and the MCP.  ODJFS may also require
      the MCP to designate contact staff for specific program
      areas.  The Medicaid Coordinator will be responsible for
      ensuring the timeliness, accuracy, completeness and responsiveness of all
      MCP submissions to ODJFS.

                


        

        


        
          	
                   

                   

                	b.	
                  A
      provider relations representative for each service area included in their
      ODJFS provider agreement. This provider relations representative can serve
      in this capacity for only one service area (as specified in Appendix
      H).

                


        

        


        As long
as the MCP serves both the CFC and ABD populations, they are not required
to have separate provider relations representatives or Medicaid
coordinators.

        


        
          	
                  4.

                	
                  All
      MCP employees are to direct all day-to-day submissions and communications
      to their ODJFS-designated Contract Administrator unless otherwise notified
      by ODJFS.

                


        

        


        
          	
                  5.

                	
                  The
      MCP must be represented at all meetings and events designated by ODJFS as
      requiring mandatory attendance.

                


        

        


        6.     
       The MCP must have an administrative
office located in Ohio.

         

        
          
            
            

          

          
            1

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                  7.

                	
                  Upon
      request by ODJFS, the MCP must submit information on the current status of
      their company’s operations not specifically covered under this provider
      agreement (for example, other product lines, Medicaid contracts in other
      states, NCQA accreditation, etc.) unless otherwise excluded by
      law.

                


        

        


        
          	
                  8.

                	
                  The
      MCP must have all new employees trained on applicable program
      requirements, and represent, warrant and certify to ODJFS that such
      training occurs, or has occurred.

                


        

        


        
          	
                  9.

                	
                  If
      an MCP determines that it does not wish to provide, reimburse, or cover a
      counseling service or referral service due to an objection to the service
      on moral or religious grounds, it must immediately notify ODJFS to
      coordinate the implementation of this change.  MCPs will be
      required to notify their members of this change at least thirty (30) days
      prior to the effective date. The MCP’s member handbook and provider
      directory, as well as all marketing materials, will need to include
      information specifying any such services that the MCP will not
      provide.

                


        

        


        
          	
                  10.

                	
                  For
      any data and/or documentation that MCPs are required to maintain, ODJFS
      may request that MCPs provide analysis of this data and/or documentation
      to ODJFS in an aggregate format, such format to be solely determined by
      ODJFS.

                


        

        


        
          	
                  11.

                	
                  The
      MCP is responsible for determining medical necessity for services and
      supplies requested for their members as specified in OAC rule
      5101:3-26-03.  Notwithstanding such responsibility, ODJFS
      retains the right to make the final determination on medical necessity in
      specific member situations.

                


        

        


        
          	
                  12.

                	
                  In
      addition to the timely submission of medical records at no cost for the
      annual external quality review as specified in OAC rule 5101:3-26-07, the
      MCP may be required  for other purposes to submit medical
      records at no cost to ODJFS and/or designee upon
  request.

                


        

        


        
          	
                  13.

                	
                  The
      MCP must notify the BMHC of the termination of an MCP panel provider
      that is designated as the primary care provider for 500 or more
      of the MCP’s CFC members. 
       The MCP must provide notification within one working day of the MCP
      becoming aware of the
termination.

                


        

         

        
          	
                  14.

                	
                  Upon
      request by ODJFS, MCPs may be required to provide written notice to
      members of any significant change(s) affecting contractual requirements,
      member services or access to
providers.

                


        

         

        
          
            
            

          

          
            2

            
              

            

          

          
            
              
                Appendix
C 

                Covered
Families and Children (CFC) population

              

            

          

        

         

        
          	
                  15.

                	
                  MCPs
      may elect to provide services that are in addition to those covered under
      the Ohio Medicaid fee-for-service program.  Before MCPs notify
      potential or current members of the availability of these services, they
      must first notify ODJFS and advise ODJFS of such planned services
      availability.  If an MCP elects to provide additional services,
      the MCP must ensure to the satisfaction of ODJFS that the services are
      readily available and accessible to members who are eligible to receive
      them.  Additional benefits must be made available to members for
      at least six (6) calendar months from date approved by
    ODJFS.

                


        

        


        
          	
                   
      

                	
                  a.

                	
                  MCPs
      are required to
      make transportation available to any member requesting transportation
      when they must travel (thirty) 30
      miles or more from their home to receive a medically-necessary
      Medicaid-covered service.  If the MCP offers transportation to
      their members as an additional benefit and this transportation benefit
      only covers a limited number of trips, the required transportation listed
      above may not be counted toward this trip
limit.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  Additional
      benefits may not vary by county within a region except out
      of necessity for transportation arrangements (e.g., bus versus
      cab).  MCPs approved to serve consumers in more than one region
      may vary additional benefits between
regions.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  MCPs
      must give ODJFS and members (ninety) 90 days prior notice
      when decreasing or ceasing any additional benefit(s).  When
      it is beyond the control of the MCP, as demonstrated to ODJFS’
      satisfaction, ODJFS must be notified within (one) 1 working
      day.

                


        

        


        
          	
                  16.

                	
                  MCPs
      must comply with any applicable Federal and State laws that pertain to
      member rights and ensure that its staff adheres to such laws when
      furnishing services to its members.  MCPs shall include a
      requirement in its contracts with affiliated providers that such providers
      also adhere to applicable Federal and State laws when providing services
      to members.

                


        

        


        
          	
                  17.

                	
                  MCPs
      must comply with any other applicable Federal and State laws (such as
      Title VI of the Civil rights Act of 1964, etc.) and other laws regarding
      privacy and confidentiality, as such may be applicable to this
      Agreement.

                


        

        


        
          	
                  18.

                	
                  Upon
      request, the MCP will provide members and potential members with a copy of
      their practice guidelines.

                


        

        


        
          	
                  19.

                	
                  The
      MCP is responsible for promoting the delivery of services in a culturally
      competent manner, as solely determined by ODJFS, to all members, including
      those with limited English proficiency (LEP) and diverse cultural and
      ethnic backgrounds.

                


        

         

        
          
            
            

          

          
            3

            
              

            

          

          
            
              
                Appendix
C 

                Covered
Families and Children (CFC) population

              

            

          

        

         

        All MCPs
must comply with the requirements specified in OAC rules 5101:3-26-03.1,
5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and 5101:3-26-08.2 for
providing assistance to LEP members and eligible individuals.  In
addition, MCPs must provide written translations of certain MCP materials in the
prevalent non-English languages of members and eligible individuals in
accordance with the following:

        


        
          	
                   
      

                	
                  a.

                	
                  When
      10% or more of the CFC eligible individuals in the MCP’s service area have
      a common primary language other than English, the MCP must translate all
      ODJFS-approved marketing materials into the primary language of that
      group.  The MCP must monitor changes in the eligible population
      on an ongoing basis and conduct an assessment no less often than annually
      to determine which, if any, primary language groups meet the 10% threshold
      for the eligible individuals in each service area.  When the 10%
      threshold is met, the MCP must report this information to ODJFS, in a
      format as requested by ODJFS, translate their marketing materials, and
      make these marketing materials available to eligible
      individuals.  MCPs must submit to ODJFS, upon request, their
      prevalent non-English language analysis of eligible individuals and the
      results of this analysis.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  When
      10% or more of an MCP's CFC members in the MCP’s service area have
      a common primary language other than English, the MCP must translate all
      ODJFS-approved member materials into the primary language of that group.
      The MCP must monitor their membership and conduct a quarterly assessment
      to determine which, if any, primary language
      groups meet the 10% threshold.  When the 10% threshold is met,
      the MCP must report this information to ODJFS, in a format as requested by
      ODJFS, translate their member materials, and make these materials
      available to their members.  MCPs must submit to ODJFS, upon
      request, their prevalent non-English language member analysis and the
      results of this analysis.

                


        

         

        
          	
                  20.

                	
                  The
      MCP must utilize a centralized database which records the special
      communication needs of all MCP members (i.e., those with limited English
      proficiency, limited reading proficiency, visual impairment, and
      hearing impairment) and the provision of related services (i.e., MCP
      materials in alternate format, oral interpretation, oral
      translation services, written translations of MCP materials, and sign
      language services).  This database must include all MCP
      member primary language information (PLI) as well as all other
      special communication needs information for MCP members, as indicated
      above, when identified by any source including but not limited to
      ODJFS, ODJFS selection services entity, MCP staff, providers, and
      members.  This centralized database must be readily
      available to MCP staff and be used in coordinating communication and
      services to members, including the selection of a PCP who speaks
      the primary language of an LEP member, when such  a provider is
      available.  MCPs must share specific communication needs information
      with their provider [e.g., PCPs, Pharmacy Benefit Managers (PBMs), and
      Third Party Administrators (TPAs)], as applicable.  MCPs must submit
      to ODJFS, upon request, detailed information regarding the MCP's member
      with special communication needs, which could include individual member
      names, their specific communication need, and any provision of special
      services to members (i.e., those special services arranged by the MCP as
      well as those services reported to the MCP which were arranged by the
      provider).  

                


        

         

        
          
            
            

          

          
            4

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  Additional
      requirements specific to providing assistance to hearing-impaired, vision
      impaired, limited reading proficient (LRP), and LEP members and eligible
      individuals are found in OAC rules 5101:3-26-03.1, 5101:3-26-05(D),
      5101:3-26-05.1(A), 5101:3-26-08, and
  5101-3-26-08.2.

                


        

        


        
          	
                  21.

                	
                  The
      MCP is responsible for ensuring that all member materials use easily
      understood language and format.  The determination of what
      materials comply with this requirement is in the sole discretion of
      ODJFS.

                


        

        


        
          	
                  22.

                	
                  Pursuant
      to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible for
      ensuring that all MCP marketing and member materials are prior approved by
      ODJFS before being used or shared with members.  Marketing and
      member materials are defined as
follows:

                


        

        


        
          	
                   
      

                	
                  a.

                	
                  Marketing
      materials are those items produced in any medium, by or on behalf of an
      MCP, including gifts of nominal value (i.e., items worth no more than
      $15.00), which can reasonably be interpreted as intended to market to
      eligible individuals.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  Member
      materials are those items developed, by or on behalf of an MCP, to fulfill
      MCP program requirements or to communicate to all members or a group of
      members.  Member health education materials that are produced by
      a source other than the MCP and which do not include any reference to the
      MCP are not considered to be member
materials.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  All
      MCP marketing and member materials must represent the MCP in an honest and
      forthright manner and must not make statements which are inaccurate,
      misleading, confusing, or otherwise misrepresentative, or which defraud
      eligible individuals or ODJFS.

                


        

         

        
          	 	
                  d.

                	All MCP marketing
      cannot contain any assertion or statement (whether written or oral) that
      the MCP is endorsed by CMS, the Federal or State government or
      similar entity.                                


        

         

        
          	
                   
      

                	
                  e.

                	
                  MCPs
      must establish positive working relationships with the CDJFS offices
      and must not aggressively solicit from local Directors, MCP County
      Coordinators, or other staff.  Furthermore, MCPs are prohibited
      from offering gifts of nominal value (i.e. clipboards, pens, coffee mugs,
      etc.) to CDJFS offices or managed care enrollment center (MCEC) staff, as
      these may influence an individual’s decision to select a particular
      MCP.

                


        

         

        
          
            
            

          

          
            5

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                  23.

                	
                  Advance
      Directives – All MCPs must comply with the requirements specified
      in 42
      CFR 422.128.  At a minimum, the MCP must:

                	
                   

                


        

        


        
          	
                   
      

                	
                  a.

                	
                  Maintain
      written policies and procedures that meet the requirements for advance
      directives, as set forth in 42 CFR Subpart I of part
  489.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  Maintain
      written policies and procedures concerning advance directives with respect
      to all adult individuals receiving medical care by or through the MCP to
      ensure that the  MCP:

                


        

                                    


                                     
  
i.           Provides
written information to all adult members concerning:

        


        
          	
                   
      

                	
                  a.

                	
                  the
      member’s rights under state law to make decisions concerning their medical
      care, including the right to accept or refuse medical or surgical
      treatment and the right to formulate advance directives.  (In
      meeting this requirement, MCPs must utilize form JFS 08095 entitled You Have the Right, or
      include the text from JFS 08095 in their ODJFS-approved member
      handbook).

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  the
      MCP’s policies concerning the implementation of those rights including a
      clear and precise statement of any limitation regarding the implementation
      of advance directives as  a matter of
  conscience;

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  any
      changes in state law regarding advance directives as soon as possible but
      no later than (ninety) 90 days after the proposed effective date of the
      change; and

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  the
      right to file complaints concerning noncompliance with the advance
      directive requirements with the Ohio Department of
  Health.

                


        

        


        
          	
                   
      

                	
                  ii.

                	
                  Provides
      for education of staff concerning the MCP’s policies and procedures on
      advance directives;

                


        

        


        
          	
                   
      

                	
                  iii.

                	
                  Provides
      for community education regarding advance directives directly
      or  in concert with other providers or
  entities;

                


        

        


        
          	
                   
      

                	
                  iv.

                	
                  Requires
      that the member’s medical record document whether or not the member has
      executed an advance directive; and

                


        

        


        
          	
                   
      

                	
                  v.

                	
                  Does
      not condition the provision of care, or otherwise discriminate against a
      member, based on whether the member has executed an advance
      directive.

                


        

         

        
          
            
            

          

          
            6

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

        
           

          24.           New Member
Materials

           

        

        Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a member handbook, a provider directory, and information on advance
directives.

        


        
          	
                   
      

                	
                  a.

                	
                  MCPs
      must use the model language specified by ODJFS for the new member
      letter.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  The
      ID card and new member letter must be mailed together to the member via a
      method that will ensure their receipt prior to the member’s effective date
      of coverage.

                	 


        

        


        
          	
                   
      

                	
                  c.

                	
                  The
      member handbook, provider directory and advance directives
      information may be mailed to the member separately from the ID
      card and new member letter.  MCPs will
      meet the timely receipt requirement for these materials if they are mailed
      to the member within (twenty-four) 24 hours of the MCP receiving the ODJFS
      produced monthly membership roster (MMR). This is provided the materials
      are mailed via a method with an expected delivery date of no more than
      five (5) days. If the member handbook, provider directory and advance
      directives information are mailed separately from the ID card and new
      member letter and the MCP is unable to mail the materials within
      twenty-four (24) hours, the member handbook, provider directory and
      advance directives information must be mailed via a method that will
      ensure receipt by no later than the effective date of coverage. If the MCP
      mails the ID card and new member letter with the other materials (e.g.,
      member handbook, provider directory, and advance directives), the MCP
      must ensure that all materials
      are mailed via a method that will ensure their receipt prior to the
      member’s effective date of
coverage.

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  MCPs
      must designate two (2) MCP staff members to receive a copy of the new
      member materials on a monthly basis in order to monitor the timely receipt
      of these materials. At least one of the staff members must receive the
      materials at their home address.

                


        

         

        25.           Call Center
Standards

         

        The MCP
must provide assistance to members through a member services toll-free call-in
system pursuant to OAC rule 5101:3-26-08.2(A)(1).  MCP member services
staff must be available nationwide to provide assistance to members through the
toll-free call-in system every Monday through Friday, at all times during the
hours of 7:00 am to 7:00 pm Eastern Time, except for the following major
holidays:

        
          	
                  ·  

                	
                  New
      Year’s Day

                


        

        
          	
                  ·  

                	
                  Martin
      Luther King’s Birthday

                


        

        
          	
                  ·  

                	
                  Memorial
      Day

                


        

        
          	
                  ·  

                	
                  Independence
      Day

                


        

        
          	
                  ·  

                	
                  Labor
      Day

                


        

        
          	
                  ·  

                	
                  Thanksgiving
      Day

                


        

        
          	
                  ·  

                	
                  Christmas
      Day

                


        

        
          	
                  ·  

                	
                  2
      optional closure days:  These days can be used independently or
      in combination with any of the major
      holiday closures but cannot both be used within the same closure
      period.  Before announcing any optional closure
      dates to members and/or staff, MCPs must receive ODJFS prior-approval
      which verifies that the optional closure days meet the specified
      criteria.

                


        

           

        
          
            
            

          

          
            7

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        If a
major holiday falls on a Saturday, the MCP member services line may be closed on
the preceding Friday.  If a major holiday falls on a Sunday, the
member services line may be closed on the following Monday.  MCP
member services closure days must be specified in the MCP’s member handbook,
member newsletter, or other some general issuance to the MCP’s members at least
(thirty) 30 days in advance of the closure.

        


        The MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day (24/7) toll-free call-in system, available
nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in system
must be staffed by appropriately trained medical personnel. For the purposes of
meeting this requirement, trained medical professionals are defined as
physicians, physician assistants, licensed practical nurses, and registered
nurses.

        


        MCPs must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and 24/7 toll-free call-in systems to
ODJFS.  ODJFS will inform the MCPs of any changes/updates to these
URAC call center standards.

         

        MCPs are not permitted to delegate grievance/appeal functions [Ohio
Administrative Code (OAC) rule 5101:3-26-08.4(A)(9)].  Therefore, the
member services call center requirement may not be met through the execution of
a Medicaid Delegation Subcontract Addendum or Medicaid Combined Services
Subcontract Addendum.

         

        26.           Notification of Optional MCP
Membership

        


        In order
to comply with the terms of the ODJFS State Plan Amendment for the managed care
program (i.e.,  42 CFR 438.50), MCPs in mandatory
membership  service areas must inform new members that MCP membership
is optional for certain populations.  Specifically, MCPs must inform
any applicable pending member or member that the following CFC populations are
not required to select an MCP in order to receive their Medicaid healthcare
benefit and what steps they need to take if they do not wish to be a member of
an MCP:

        
          	
                  -  

                	
                  Indians
      who are members of federally-recognized
tribes.

                


        

        
          	
                  -  

                	
                  Children
      under 19 years of age who are:

                


        

        
          	
                  o  

                	
                  Eligible
      for Supplemental Security Income under title
  XVI;

                


        

        
          	
                  o  

                	
                  In
      foster care or other out-of-home
placement;

                


        

        
          	
                  o  

                	
                  Receiving
      foster care of adoption assistance;

                


        

        
          	
                  o  

                	
                  Receiving
      services through the Ohio Department of Health’s Bureau for Children with
      Medical Handicaps (BCMH) or any other family-centered, community-based,
      coordinated care system that receives grant funds under section
      501(a)(1)(D) of title V, and is defined by the State in terms of either
      program participation or special health care
  needs.

                


        

         

        
          
            
            

          

          
            8

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        27.           HIPAA Privacy Compliance
Requirements

        


        The
Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have agreements with
MCPs as a means of obtaining satisfactory assurance that the MCPs will
appropriately safeguard all personal identified health
information.  Protected Health Information (PHI) is information
received from or on behalf of ODJFS that meets the definition of PHI as defined
by HIPAA and the regulations promulgated by the United States Department of
Health and Human Services, specifically 45 CFR 164.501, and any amendments
thereto. MCPs must agree to the following:

        


        
          	
                   
      

                	
                  a.

                	
                  MCPs
      shall not use or disclose PHI other than is permitted by this agreement or
      required by law.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  MCPs
      shall use appropriate safeguards to prevent unauthorized use or disclosure
      of PHI.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  MCPs
      shall report to ODJFS any unauthorized use or disclosure of PHI of
      which it becomes aware.  Any breach by the MCP or its
      representatives of protected health information (PHI) standards shall be
      immediately reported to the State HIPAA Compliance Officer through the
      Bureau of Managed Health Care.  MCPs must provide documentation
      of the breach and complete all actions ordered by the HIPAA Compliance
      Officer.

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  MCPs
      shall ensure that all its agents and subcontractors agree to these same
      PHI conditions and restrictions.

                


        

        


        e.            
MCPs shall make PHI available for access as required by law.

        


        
          	
                   
      

                	
                  f.

                	
                  MCP
      shall make PHI available for amendment, and incorporate amendments as
      appropriate as required by law.

                


        

        


        
          	
                   
      

                	
                  g.

                	
                  MCPs
      shall make PHI disclosure information available for accounting as required
      by law.

                


        

        


        
          	
                   
      

                	
                  h.

                	
                  MCPs
      shall make its internal PHI practices, books and records available to the
      Secretary of Health and Human Services (HHS) to determine
      compliance.

                


        

        


        
          	
                   
      

                	
                  i.

                	
                  Upon
      termination of their agreement with ODJFS, the MCPs, at ODJFS’ option,
      shall return to ODJFS, or destroy, all PHI in its possession, and keep no
      copies of the information, except as requested by ODJFS or required by
      law.

                


        

        


        
          	
                   
      

                	
                  j.

                	
                  ODJFS
      will propose termination of the MCP’s provider agreement if ODJFS
      determines that the MCP has violated a material breach under this section
      of the agreement, unless inconsistent with statutory obligations of ODJFS
      or the MCP.

                


        

        


        
          	
                  28.

                	
                  Electronic
      Communications – MCPs are required to purchase/utilize Transport
      Layer Security (TLS) for all e-mail communication between ODJFS and the
      MCP.  The MCP’s e-mail gateway must be able to support the
      sending and receiving of e-mail using Transport Layer Security (TLS) and
      the MCP’s gateway must be able to enforce the sending and receiving of
      email via TLS.

                


        

         

        
          
            
            

          

          
            9

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        29.           MCP Membership acceptance,
documentation and reconciliation

        


        
          	
                   
      

                	
                  a.

                	
                  Selection Services
      Contractor:  The MCP shall provide to the MCEC ODJFS
      prior-approved MCP materials and directories for distribution to eligible
      individuals who request additional information about the
    MCP.

                


        

         

        
          	
                   
      

                	
                  b.

                	
                  Monthly Reconciliation
      of Membership and Premiums: The MCP shall reconcile member data as
      reported on the MCEC produced consumer contact record (CCR) with the
      ODJFS-produced monthly member roster (MMR) and report to the ODJFS any
      difficulties in interpreting or reconciling information
      received.  Membership reconciliation questions must be
      identified and reported to the ODJFS prior to the first of the month to
      assure that no member is left without coverage. The MCP shall reconcile
      membership with premium payments and delivery payments as reported on the
      monthly remittance advice (RA).

                


        

        


        
          	
                   
      

                	
                  The
      MCP shall work directly with the ODJFS, or other ODJFS-identified entity,
      to resolve any difficulties in interpreting or reconciling premium
      information.  Premium reconciliation questions must be
      identified within thirty (30) days of receipt of the RA.  Monthly
      reconciliation data must be submitted in the format specified by
      ODJFS.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  Monthly Premiums and
      Delivery Payments: The MCP must be able to receive monthly premiums
      and delivery payments in a method specified by ODJFS.  (ODJFS
      monthly prospective premium and delivery payment issue dates are provided
      in advance to the MCPs.) Various retroactive premium payments (e.g.,
      newborns), and recovery of premiums paid (e.g., retroactive terminations
      of membership for children in custody, deferments, etc.,) may occur via
      any ODJFS weekly remittance.

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  Hospital/Inpatient
      Facility Deferment: When an MCP learns of a currently hospitalized
      member’s intent to disenroll through the CCR or the 834, the disenrolling
      MCP must notify the hospital/inpatient facility and treating providers as
      well as the enrolling MCP of the change in enrollment within five (5)
      business days of receipt of the CCR or 834. The
      disenrolling MCP must notify the inpatient facility that it will remain
      responsible for the inpatient facility charges through the date of
      discharge; and must notify the treating providers that it will remain
      responsible for provider charges through the date of
      disenrollment.

                


        

         

        
          	 	 	When the enrolling
      MCP learns through the disenrolling MCP, through ODJFS or other means,
      that a new member who was previously enrolled with another MCP was
      admitted prior to the effective date of enrollment and remains an
      inpatient on the effective date of enrollment, the enrolling MCP shall
      contact the hospital/inpatient facility within five (5) business days of
      learning of the hospitalization.  The enrolling MCP shall verify
      that it is responsible for all medically necessary Medicaid covered
      services from the effective date of MCP membership, including treating
      provider services related to the inpatient stay; the enrolling MCP must
      reiterate that the admitting/disenrolling MCP remains responsible for the
      hospital/inpatient facility charges through the date of
      discharge.  The enrolling MCP shall work with the
      hospital/inpatient facility to facilitate discharge planning and authorize
      services as needed.


        

         

        
          	 	 	 When
      an MCP learns that a new member who was previously on Medicaid fee for
      service was admitted prior to the effective date of enrollment and remains
      an inpatient on the effective date of enrollment, the enrolling MCP shall
      notify the hospital/ inpatient facility and treating providers that the
      MCP may not be the payer. The MCP shall work with hospital/inpatient
      facility, treating providers and the ODJFS to assure that discharge
      planning assures continuity of care and accurate payment. Notwithstanding
      the MCP’s right to request a hospital deferment up to six (6) months
      following the member’s effective date, when the enrolling MCP learns of a
      deferment-eligible hospitalization, the MCP shall notify the ODJFS and request the
      deferment within five (5) business days of learning of the potential
      deferment.


        

         

        
          
            
            

          

          
            10

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  e.

                	
                  Just Cause
      Requests: The MCP shall
      follow procedures as specified by ODJFS in assisting the ODJFS in
      resolving member requests for member-initiated requests affecting
      membership.

                


        

        


        
          	
                   
      

                	
                  f.

                	
                  Newborn
      Notifications:  The MCP is required to submit newborn
      notifications to ODJFS in accordance with the ODJFS Newborn Notification
      File and Submissions
Specifications.

                


        

        


        
          	
                   
      

                	
                  g.

                	
                  Eligible
      Individuals:  If an eligible individual contacts the MCP,
      the MCP must provide any MCP-specific managed care program information
      requested.  The MCP must not attempt to assess the eligible
      individual’s health care needs. However, if the eligible individual
      inquires about continuing/transitioning health care services, MCPs shall
      provide an assurance that all MCPs must cover all medically necessary
      Medicaid-covered health care services and assist members with
      transitioning their health care
services.

                


        

        


        
          	
                   
      

                	
                  h.

                	
                  Pending
      Member

                


        

        


        
          	
                   
      

                	
                  If
      a pending member (i.e., an eligible individual subsequent to
      plan selection or assignment, but prior to their membership effective
      date) contacts the selected MCP,  the MCP must provide any
      membership information requested, including but not limited to,
      assistance in determining whether the current medications require
      prior authorization. The MCP must also ensure that any care
      coordination (e.g., PCP selection, prescheduled services and
      transition of services) information provided by the pending member is
      logged in the MCP’s system and forwarded to the appropriate MCP staff
      for processing as required.  MCPs may confirm
      any information provided on the CCR at this time.  Such
      communication does not constitute confirmation of membership.  MCPs
      are prohibited from initiating contact with a pending member.  Upon
      receipt of the 834, the MCP may contact a pending member to confirm
      information provided on the CCR or the 834, assist with care coordination
      and transition of care, and inquire if the pending member has any
      membership questions.   

                


        

         

        i.          
   Transition of Fee-For-Service
Members

        


        Providing
care coordination for prescheduled health services and existing care treatment
plans, is critical for members transitioning from Medicaid fee-for service (FFS)
to managed care.  Therefore, MCPs must:

         

        
          	
                   
      

                	
                  i.

                	
                  Allow
      their new members that are transitioning from Medicaid fee-for-service to
      receive services from out-of-panel providers if the member or provider
      contacts the MCP to discuss the scheduled health services in advance
      of the service date and one of the following
  applies:

                


        

         

        
          
            
            

          

          
            11

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  a.

                	
                  The
      member is in her third trimester of pregnancy and has an established
      relationship with an obstetrician and/or delivery
  hospital;

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  The
      member has been scheduled for an inpatient/outpatient surgery and has
      been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40
      (surgical procedures would also include follow-up care as
      appropriate);

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  The
      member has appointments within the initial month of MCP membership with
      specialty physicians that were scheduled prior to the effective date of
      membership; or

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  The
      member is receiving ongoing chemotherapy or radiation
      treatment.

                


        

        


        If
contacted by the member, the MCP must contact the provider’s office as
expeditiously as the situation warrants to confirm that the service(s) meets the
above criteria.

         

        
          	 	
                  ii.  

                	
                  Allow
      their new members that are transitioning from Medicaid fee-for-service to
      continue receiving home care services (i.e., nursing, aide, and
      skilled therapy services) and private duty nursing (PDN) services if the
      member or provider contacts the MCP to discuss the health services in
      advance of the service date.  These services must be covered
      from the date of
      the member or provider contact at the current service level, and with the
      current provider, whether a panel or out-of-panel provider, until the MCP
      conducts a medical necessity review and renders an authorization decision
      pursuant to OAC rule 5101:3-26-03.1.  As soon as the MCP becomes
      aware of the member’s current home care services, the MCP must initiate
      contact with the current provider and member as applicable to ensure
      continuity of care and coordinate a transfer of services to a panel
      provider, if
appropriate.

                


        


        
        

        
          	
                   
      

                	
                  iii.

                	
                  Honor
      any current fee-for-service prior authorization to allow their new members
      that are transitioning from Medicaid fee-for-service to receive services
      from the authorized provider, whether a panel or out-of-panel provider,
      for the following approved
services:

                


        

         

        
          
            
            

          

          
            12

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  a.

                	
                  an
      organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC
      rule 5101:3-2-07.1 and 2.b.v of Appendix
G;

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  dental
      services that have not yet been
received;

                


        

        


        
          	 	
                  c.  

                	
                  vision
      services that have not yet been
received;

                


        

        


        
          	 	
                  d.  

                	
                  durable
      medical equipment (DME) that has not yet been received.  Ongoing DME
      services and supplies are to be covered by the MCP as
      previously-authorized until the MCP conducts a medical necessity review
      and renders an authorization decision pursuant to OAC rule
      5101:3-26-03.1.

                


        

         

        
          	 	
                  e.  

                	
                  private
      duty nursing (PDN) services.  PDN services must be covered at
      the previously-authorized service level until the MCP conducts a medical
      necessity review and renders an authorization decision pursuant to OAC
      rule 5101:3-26-03.1.

                


        

         

        As soon
as the MCP becomes aware of the member’s current fee-for-service authorization
approval, the MCP must initiate contact with the authorized provider and member
as applicable to ensure continuity of care.  The MCP must implement a
plan to meet the member’s immediate and ongoing medical needs and, coordinate
the transfer of services to a panel provider, if appropriate. For organ, bone
marrow or hematapoietic stem cell transplants, MCPs must receive prior approval
from ODJFS to transfer services to a panel provider.

         

        When an
MCP medical necessity review results in a decision to reduce, suspend, or
terminate services previously authorized by fee-for-service Medicaid, the MCP
must notify the member of their state hearing rights no less than 15 calendar
days prior to the effective date of the MCP’s proposed action, per rule
5101:3-26-08.4 of the Administrative Code.

         

        
          	
                   
      

                	
                  iv.

                	
                  Reimburse
      out-of-panel providers that agree to provide the transition services at
      100% of the current Medicaid fee-for-service provider rate for the
      service(s) identified in Section 29.i. (i., ii., and iii.) of this
      appendix.

                


        

         

        
          
            
            

          

          
            13

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  v.

                	
                  Document
      the provision of transition of services identified in Section 29.i. (i.,
      ii., and iii.) of this appendix as
follows:

                


        

        


        
          	
                   
      

                	
                  a.

                	
                  For
      non-panel providers, notification to the provider confirming the
      provider’s agreement/disagreement to provide the service and accept 100%
      of the current Medicaid fee-for-service rate as payment.  If the
      provider agrees, the distribution of the MCP’s materials as outlined in
      Appendix G.3.e.

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  Notification
      to the member of the non-panel provider’s agreement /disagreement to
      provide the service.  If the provider disagrees, notification to
      the member of the MCP’s availability to assist with locating a provider as
      expeditiously as the member’s health condition
  warrants.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  For
      panel providers, notification to the provider and member confirming the
      MCP’s responsibility to cover the
service.

                


        

        


        
          	
                   
      

                	
                  MCPs
      must use the ODJFS-specified model language for the provider and member
      notices and maintain documentation of all member and/or provider contacts
      relating to such services.

                


        

        
        

        
        

         

        
          	
                   30.

                	
                  Health Information
      System Requirements

                


        

         

        The
ability to develop and maintain information management systems capacity is
crucial to successful plan performance. ODJFS therefore requires MCPs to
demonstrate their ongoing capacity in this area by meeting several related
specifications.

        


        a.         
   Health Information System

        


        
          	
                   
      

                	
                  i.

                	
                  As
      required by 42 CFR 438.242(a), each MCP must maintain a health information
      system that collects, analyzes, integrates, and reports
      data.  The system must provide information on areas including,
      but not limited to, utilization, grievances and appeals, and MCP
      membership terminations for other than loss of Medicaid
      eligibility.

                


        

        


        
          	
                   
      

                	
                  ii.

                	
                  As
      required by 42 CFR 438.242(b)(1), each MCP must collect data on member and
      provider characteristics and on services furnished to its
      members.

                


        

        


        
          	
                   
      

                	
                  iii.

                	
                  As
      required by 42 CFR 438.242(b)(2), each MCP must ensure that data received
      from providers is accurate and complete by verifying the accuracy and
      timeliness of reported data; screening the data for completeness, logic,
      and consistency; and collecting service information in standardized
      formats to the extent feasible and
appropriate.

                


        

        


        
          	
                   
      

                	
                  iv.

                	
                  As
      required by 42 CFR 438.242(b)(3), each MCP must make all collected data
      available upon request by ODJFS or the Center for Medicare and Medicaid
      Services (CMS).

                


        

        


        
          	
                   
      

                	
                  v.

                	
                  Acceptance
      testing of any data that is electronically submitted to ODJFS is
      required:

                


        

         

        
          
            
            

          

          
            14

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  a.

                	
                  Before
      an MCP may submit production files ODJFS-specified formats;
      and/or

                


        

        
          	
                   
      

                	
                  b.

                	
                  Whenever
      an MCP changes the method or preparer of the electronic media;
      and/or

                


        

        
          	
                   
      

                	
                  c.

                	
                  When
      the ODJFS determines an MCP’s data submissions have an unacceptably high
      error rate.

                


        

        


        MCPs that
change or modify information systems that are involved in producing any type of
electronically submitted files, either internally or by changing vendors, are
required to submit to ODJFS for review and approval a transition plan including
the submission of test files in the ODJFS-specified formats.  Once an
acceptable test file is submitted to ODJFS, as determined solely by ODJFS, the
MCP can return to submitting production files.  ODJFS will inform MCPs
in writing when a test file is acceptable.  Once an MCP’s new or
modified information system
is operational,
that MCP will have up to ninety (90) days to submit an acceptable test file and
an acceptable production file.

         

        Submission of test files can start before the new or modified
information system is in
production.  ODJFS reserves the right to verify any
MCP’s capability to report elements in the minimum data set prior to
executing the provider agreement for the next contract period. Penalties for
noncompliance with this requirement are specified in Appendix N, Compliance
Assessment System of the Provider Agreement.

         

        b.           
 Electronic Data Interchange and Claims Adjudication
Requirements

         

        Claims
Adjudication

        


        The MCP
must have the capacity to electronically accept and adjudicate all claims to
final status (payment or denial).  Information on claims submission
procedures must be provided to non-contracting providers within thirty
(30) days of a request.  MCPs must inform providers of its
ability to electronically process and adjudicate claims and the process for
submission.  Such information must be initiated by the MCP and not
only in response to provider requests.

        


        The MCP
must notify providers who have submitted claims of claims status
[paid, denied, pended (suspended)] within one month of
receipt.  Such notification may be in the form of a claim
payment/remittance advice produced on a routine monthly, or more frequent,
basis.

        


        Electronic Data
Interchange

        The MCP
shall comply with all applicable provisions of HIPAA including electronic data
interchange (EDI) standards for code sets and the following electronic
transactions:

        Health
care claims;

        Health care claim status request and
response;

        Health care payment and remittance
status;

        Standard code sets; and

        National Provider Identifier
(NPI).

         

        
          
            
            

          

          
            15

            
              

            

          

          
            
              Appendix
C

              Covered
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        Each EDI
transaction processed by the MCP shall be implemented inconformance with the
appropriate version of the transaction implementation guide,
as specified by applicable federal rule or
regulation.

         

        The MCP
must have the capacity to accept the following transactions from the Ohio
Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance with
the 820 and 834 Transaction Companion Guides issued by ODJFS:

        


        ASC X12
820 - Payroll Deducted and Other Group Premium Payment for Insurance Products;
and

        


        ASC X12 834 - Benefit Enrollment and
Maintenance.

         

        The MCP
shall comply with the HIPAA mandated EDI transaction standards and code sets no
later than the required compliance dates as set forth in the federal
regulations.

        


        Documentation of Compliance
with Mandated EDI Standards

        The
capacity of the MCP and/or applicable trading partners and business associates
to electronically conduct claims processing and related transactions in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS,  as outlined
below.

        


        Verification of Compliance
with HIPAA (Health Insurance Portability and accountability Act of
1995)

        


        MCPs
shall comply with the transaction standards and code sets for sending and
receiving applicable transactions as specified in 45 CFR Part 162 – Health
Insurance Reform:  Standards for Electronic Transactions (HIPAA
regulations)  In addition the MCP must enter into the appropriate
trading partner agreement and implemented standard code sets.  If the
MCP has obtained third-party certification of HIPAA compliance for any of the
items listed below, that certification may be submitted in lieu of the MCP’s
written verification for the applicable item(s).

        


        i.           
 Trading Partner Agreements

        ii.          
 Code Sets

        iii.        
  Transactions

                        

                                         
    
a.           Health Care
Claims or Equivalent Encounter Information

        (ASC X12N 837 & NCPDP
5.1

               b.           Eligibility
for a Health Plan (ASC X12N 270/271)

                                                   
   c.           Referral
Certification and Authorization (ASC X12N 278)

                                        
             
d.           Health
Care Claim Status (ASC X12N 276/277)

                                                 
     e.           Enrollment
and Disenrollment in a Health Plan (ASC X12N 834)

                                                  
    f.           Health
Care Payment and Remittance Advice (ASC X12N 835)

         
g.           Health Plan
Premium Payments (ASC X12N 820)

        
               
h.           Coordination
of Benefits

        


        
          
             


          

          
            16

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population 

            

          

        

         

        Trading Partner Agreement
with ODJFS

        MCPs must
complete and submit an EDI trading partner agreement in a format specified by
the ODJFS.  Submission of the copy of the trading partner agreement
prior to entering into this Agreement may be waived at the discretion of ODJFS;
if submission prior to entering into this Agreement is waived, the trading
partner agreement must be submitted at a subsequent date determined by
ODJFS.

        


        Noncompliance
with the EDI and claims adjudication requirements will result in the imposition
of penalties, as outlined in Appendix N, Compliance Assessment System, of the
Provider Agreement.

        


        c.          
  Encounter
Data Submission Requirements

        


        General
Requirements

        Each MCP
must collect data on services furnished to members through an encounter data
system and must report encounter data to the ODJFS. MCPs are required to submit
this data electronically to ODJFS on a monthly basis in the following standard
formats:

        


        
          	
                  ·  

                	
                  Institutional
      Claims - UB92 flat file

                


        

        
          	
                  ·  

                	
                  Noninstitutional
      Claims - National standard format

                


        

        
          	
                  ·  

                	
                  Prescription
      Drug Claims - NCPDP

                


        

        


        ODJFS
relies heavily on encounter data for monitoring MCP performance. The ODJFS uses
encounter data to measure clinical performance, conduct access and utilization
reviews, reimburse MCPs for newborn deliveries and aid in setting MCP capitation
rates.  For these reasons, it is important that encounter data is
timely, accurate, and complete. Data quality, performance measures and standards
are described in the Agreement.

        


        An
encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and the provider. For
example, if a member had an emergency department visit and was examined by a
physician, this would constitute two encounters, one related to the hospital
provider and one related to the physician provider. However, for the purposes of
calculating a utilization measure, this would be counted as a single emergency
department visit.  If a member visits their PCP and the PCP examines
the member and has laboratory procedures done within the office, then this is
one encounter between the member and their PCP.

         

        If the
PCP sends the member to a lab to have procedures performed, then this is two
encounters; one with the PCP and another with the lab.  For pharmacy
encounters, each prescription filled is a separate encounter.

         

        
          
            
            

          

          
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C

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        Encounters
include services paid for retrospectively through fee-for-service payment
arrangements, and prospectively through capitated arrangements. Only encounters
with services (line items) that are paid by the MCP, fully or in part, and for
which no further payment is anticipated, are acceptable encounter data
submissions, except for immunization services. Immunization services submitted
to the MCP must be submitted to ODJFS if these services were paid for by another
entity (e.g., free vaccine program).

        


        All other
services that are unpaid or paid in part and for which the MCP anticipates
further payment (e.g., unpaid services rendered during a delivery of a newborn)
may not be submitted to ODJFS until they are paid. Penalties for noncompliance
with this requirement are specified in Appendix N, Compliance Assessment System
of the Agreement.

        


        Acceptance
Testing

        The MCP
must have the capability to report all elements in the Minimum Data Set as set
forth in the ODJFS Encounter Data Specifications and must submit a test file in
the ODJFS-specified medium in the required formats prior to contracting or prior
to an information systems replacement or update.

        


        
          	
                   
      

                	
                  Acceptance
      testing of encounter data is required as specified in Section 29(a)(v) of
      this Appendix.

                


        

        


        Encounter Data File
Submission Procedures

        A
certification letter must accompany the submission of an encounter data file in
the ODJFS-specified medium. The certification letter must be signed by the MCP’s
Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
who has delegated authority to sign for, and who reports directly to, the MCP’s
CEO or CFO.

        


        Timing of Encounter Data
Submissions

        ODJFS
recommends that MCPs submit encounters no more than thirty-five (35) days after
the end of the month in which they were paid. For example, claims paid in
January are due March 5.  ODJFS recommends that MCPs submit files in
the ODJFS-specified medium by the 5th of each month. This will help to ensure
that the encounters are included in the ODJFS master file in the same month in
which they were submitted.


        
          
             


          

          
            18

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population 

            

          

        

         

        d.           
Information Systems
Review

        


        ODJFS or
its designee may review the information system capabilities of each MCP, before
ODJFS enters into a provider agreement with a new MCP, when a participating MCP
undergoes a major information system upgrade or change, when there is
identification of significant information system problems, or at ODJFS’
discretion. Each MCP must participate in the review. The review will assess the
extent to which MCPs are capable of maintaining a health information system
including producing valid encounter data, performance measures, and other data
necessary to support quality assessment and improvement, as well as managing the
care delivered to its members.

        


        The
following activities, at a minimum, will be carried out during the
review.  ODJFS or its designee will:

        


        
          	
                   
      

                	
                  i.

                	
                  Review
      the Information Systems Capabilities Assessment (ISCA) forms, as developed
      by CMS; which the MCP will be required to
  complete.

                


        

        


        ii.           Review
the completed ISCA and accompanying documents;

        


        
          	
                   
      

                	
                  iii.

                	
                  Conduct
      interviews with MCP staff responsible for completing the ISCA, as well as
      staff responsible for aspects of the MCP’s information systems
      function;

                


        

        


        
          	
                   
      

                	
                  iv.

                	
                  Analyze
      the information obtained through the ISCA, conduct follow-up interviews
      with MCP staff, and write a statement of findings about the MCP’s
      information system.

                


        

        


        v.           Assess
the ability of the MCP to link data from multiple sources;

        


        vi.           Examine
MCP processes for data transfers;

        


        
          	
                   
      

                	
                  vii.

                	
                  If
      an MCP has a data warehouse, evaluate its structure and reporting
      capabilities;

                


        

        


        
          	
                   
      

                	
                  viii.

                	
                  Review
      MCP processes, documentation, and data files to ensure that they comply
      with state specifications for encounter data submissions;
    and

                


        

        


        
          	
                   
      

                	
                  ix.

                	
                  Assess
      the claims adjudication process and capabilities of the
    MCP.

                


        

         

        
          
            
            

          

          
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              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        31.           Delivery
Payments

        


        MCPs will
be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the ODJFS Methods for Reimbursing for
Deliveries (as specified in Appendix L). The delivery payment represents
the facility and professional service costs associated with the delivery event
and postpartum care that is rendered in the hospital immediately following the
delivery event; no prenatal or neonatal experience is included in the delivery
payment.

        


        If a
delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and is not entitled to receive payment for the delivery. MCPs
are required to submit all delivery encounters to ODJFS no later than one year
after the date of the delivery. Delivery encounters which are submitted after
this time will be denied payment.  MCPs will receive notice of the
payment denial on the remittance advice.

        


        If an MCP
is denied payment through ODJFS’ automated payment system because the delivery
encounter was not submitted within a year of the delivery date, then it will be
necessary for the MCP to contact BMHC staff to receive
payment.  Payment will be made for the delivery, at the discretion of
ODJFS if a payment had not been made previously for the same
delivery.

        


        To
capture deliveries outside of institutions (e.g., hospitals) and deliveries in
hospitals without an accompanying physician encounter, both the institutional
encounters (UB-92) and the noninstitutional encounters (NSF) are searched for
deliveries.

        


        If a
physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are submitted, only one payment will be made. The method for
reimbursing for deliveries includes the delivery of stillborns where the MCP
incurred costs related to the delivery.

        


        Rejections

        If a
delivery encounter is not submitted according to ODJFS specifications, it will
be rejected and MCPs will receive this information on the exception report (or
error report) that accompanies every file in the ODJFS-specified format.
Tracking, correcting and resubmitting all rejected encounters is the
responsibility of the MCP and is required by ODJFS.


        
          
             


          

          
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              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        Timing of Delivery
Payments

        MCPs will
be paid monthly for deliveries.  For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will be
reimbursed in March. The delivery payment will cover any encounters submitted
with the monthly encounter data submission regardless of the date of the
encounter, but will not cover encounters that occurred over one year
ago.

        


        This
payment will be a part of the weekly update (adjustment payment) that is in
place currently.  The third weekly update of the month will include
the delivery payment.  The remittance advice is in the same format as
the capitation remittance advice.

        


        Updating and Deleting
Delivery Encounters

        The
process for updating and deleting delivery encounters is handled differently
from all other encounters. See the ODJFS Encounter Data
Specifications for detailed instructions on updating and deleting
delivery encounters.

        


        The
process for deleting delivery encounters can be found on page 35 of the UB-92
technical specifications (record/field 20-7) and page III-47 of the NSF
technical specifications (record/field CA0-31.0a).

        


        Auditing of Delivery
Payments

        A
delivery payment audit will be conducted periodically. If medical records do not
substantiate that a delivery occurred related to the payment that was made, then
ODJFS will recoup the delivery payment from the MCP. Also, if it is determined
that the encounter which triggered the delivery payment was not a paid
encounter, then ODJFS will recoup the delivery payment.

        


        
          	
                  32.

                	
                  If
      the MCP will be using the Internet functions that will allow approved
      users to access member information (e.g., eligibility verification), the
      MCP must receive prior approval from ODJFS that verifies that the proper
      safeguards, firewalls, etc., are in place to protect member
      data.

                


        

        


        
          	
                  33.

                	
                  MCPs
      must receive prior written approval from ODJFS before adding any
      information to their website that would require ODJFS prior approval in
      hard copy form (e.g., provider listings, member handbook
      information).

                


        

        


        
          	
                  34.

                	
                  Pursuant
      to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
      holding a member liable for services provided to the member in the event
      that the ODJFS fails to make payment to the
MCP.

                


        

         

        
          	
                  35.

                	
                  In
      the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must
      cover the continued provision of services to members until the end of the
      month in which insolvency has occurred, as well as the continued provision
      of inpatient services until the date of discharge for a member who is
      institutionalized when insolvency
occurs.

                


        

         

        
          
            
            

          

          
            21

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                  36.

                	
                  Franchise Fee
      Assessment Requirements

                


        

        


        
          	
                   
      

                	
                  a.

                	
                  Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar
      quarter as required by ORC Section 5111.176.  The current fee
      to be paid is an amount equal to 5.5 percent of the managed care
      premiums, minus Medicare
      premiums that the MCP received from any payer in the quarter to which the
      fee applies.  Any premiums the MCP returned or refunded to
      members or premium payers during that quarter are excluded from the
      fee.

                	
                   

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  The
      franchise fee is due to ODJFS in the ODJFS-specified format on or before
      the 30th day following the end of the calendar quarter to which the fee
      applies.

                


        

        


        
          	
                   
      

                	
                  c.

                	
                  At
      the time the fee is submitted, the MCP must also submit to ODJFS a
      completed form and any supporting documentation pursuant to ODJFS
      specifications.

                


        

        


        
          	
                   
      

                	
                  d.

                	
                  Penalties
      for noncompliance with this requirement are specified in Appendix N,
      Compliance Assessment System of the Provider Agreement and in ORC Section
      5111.176.

                


        

         

        37.           Information Required for MCP
Websites

        


        
          	
                   
      

                	
                  a.

                	
                  On-line
      Provider
      Directory – MCPs must have an internet-based provider directory
      available in the same format as their ODJFS-approved provider directory,
      that allows members to electronically search for the MCP panel providers
      based on name, provider type, geographic proximity, and population (as
      specified in Appendix H).  MCP provider directories must include all
      MCP-contracted providers [except as specified by ODJFS] as well as certain
      ODJFS non-contracted providers. 

                


        

        


        
          	
                   
      

                	
                  b.

                	
                  On-line Member
      Website - MCPs must have a secure internet-based website which
      provides members the ability to submit questions, comments, grievances,
      and appeals,  and receive a response (members must be given the
      option of a return e-mail or phone call).  MCP responses to
      questions or comments must be made within one working day of
      receipt.  MCP responses to grievances and appeals must adhere to
      the timeframes specified in OAC rule 5101:3-26-08.4.  The member
      website must be regularly updated to include the most current
      ODJFS-approved materials, although this website must not be the only means
      for notifying members of new and/or revised MCP information (e.g., change
      in holiday closures, changes in additional benefits, revisions to approved
      member materials.)

                


        


        The MCP
member website must also include, at a minimum, the following information which
must be accessible to members and the general public without any log-in
restrictions by October 1, 2008: (1) MCP contact information, including the
MCP’s toll-free member services phone number, service hours, and closure dates;
(2) a list of counties covered in the MCP’s service area; (3) the ODJFS-approved
MCP member handbook, recent newsletters and announcements; (4) the MCP’s on-line
provider directory as referenced in section 36(a) of this appendix; (5) the
MCP’s current preferred drug list (PDL), including an explanation of the list,
which drugs require prior authorization (PA), and how to initiate a PA; and (6)
the MCP’s current list of drugs covered only with PA, how to initiate a PA, and
the MCP’s policy for covering name brand drugs. MCPs must ensure that all
website member information and materials are clearly labeled for CFC members
and/or ABD members, as applicable.  ODJFS may require MCPs to include
additional information on the member website as needed.

         

        
          
            
            

          

          
            22

            
              

            

          

          
            
              Appendix
C

              Covered
Families and Children (CFC) population

            

          

        

         

        
          	
                   
      

                	
                  c.

                	
                  On-line Provider
      Website – MCPs
      must have a secure internet-based website for contracting providers
      through which providers can confirm a consumer’s enrollment and through
      which providers can submit and receive responses to prior authorization
      requests (an e-mail process is an acceptable substitute if the website
      includes the MCP’s e-mail address for such
  submissions).

                


        

        


        The MCP
provider website must also include, at a minimum, the following information
which must be accessible to providers and the general public without any log-in
restrictions by October 1, 2008: (1) MCP contact information, including the
MCP’s designated contact for provider issues; (2) a list of counties covered in
the MCP’s service area; (3) the MCP’s provider manual, recent newsletters and
announcements; (4) the MCP’s on-line  provider directory as referenced
in section 36(a) of this appendix; (5) the MCP’s current PDL, including an
explanation of the list, which drugs require PA, and how to initiate a PA; and
(6) the MCP’s current list of drugs covered only with PA, how to initiate a PA,
and the MCP’s policy for covering name brand drugs.  MCPs must ensure
that all website information and materials are clearly labeled for CFC members
and/or ABD members, as applicable.   ODJFS may require MCPs to
include additional information on the provider website as needed.

        


        
          	
                  38.

                	
                  MCPs
      must provide members with a printed version of their PDL and PA lists,
      upon request.

                


        


        39.           MCPs
must not use, or propose to use, any offshore programming or call center
services in fulfilling the program requirements.

        


        40.           Coordination of
Benefits

        


        When a
claim is denied due to third party liability, the managed care plan must timely
share appropriate and available information regarding the third party to the
provider for the purposes of coordination of benefits, including, but not
limited to third party liability information received from the Ohio Department
of Job and Family Services.

        


        
          	
                  41.

                	
                  MCP
      submissions with due dates that fall on a weekend or holiday are due the
      next business day.

                


        

         

        
          
             


          

          
            23

            
              

            

          

          
            
              Appendix
D

              Covered
Families and Children (CFC) population  

            

          

        

      

       

      APPENDIX
D

      


      ODJFS
RESPONSIBILITIES

      CFC
ELIGIBLE POPULATION

      


      The
following are ODJFS responsibilities or clarifications that are not otherwise
specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
provider agreement.

      


      General
Provisions

      


      
        	
                1.

              	
                ODJFS
      will provide MCPs with an opportunity to review and comment on the
      rate-setting time line and proposed rates, and proposed changes to the OAC
      program rules or the provider
agreement.

              


      

      


      
        	
                2.

              	
                ODJFS
      will notify MCPs of managed care program policy and procedural changes
      and, whenever possible, offer sufficient time for comment and
      implementation.

              


      

      


      
        	
                3.

              	
                ODJFS
      will provide regular opportunities for MCPs to receive program updates and
      discuss program issues with ODJFS
staff.

              


      

      


      
        	
                4.

              	
                ODJFS
      will provide technical assistance sessions where MCP attendance and
      participation is required. ODJFS will also provide optional technical
      assistance sessions to MCPs, individually or as a
  group.

              


      

      


      
        	
                5.

              	
                ODJFS
      will provide MCPs with an annual MCP Calendar of Submissions outlining
      major submissions and due dates.

              


      

      


      
        	
                6.

              	
                ODJFS
      will identify contact staff, including the Contract Administrator,
      selected for each MCP.

              


      

      


      
        	
                7.

              	
                ODJFS
      will recalculate the minimum provider panel specifications  if
      ODJFS determines that significant changes have occurred in the
      availability of specific provider types and the number and composition of
      the eligible population.

              


      

      


      
        	
                8.

              	
                ODJFS
      will recalculate the geographic accessibility standards, using the
      geographic information systems (GIS) software, if ODJFS determines that
      significant changes have occurred in the availability of specific provider
      types and the number and composition of the eligible population and/or the
      ODJFS provider panel
specifications.

              


      

      


      
        	
                9.

              	
                On
      a monthly basis, ODJFS will provide MCPs with an electronic file
      containing their MCP’s provider panel as reflected in the ODJFS Provider
      Verification System (PVS) database, or other designated
      system.

              


      

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
D

            Covered
Families and Children (CFC) population  

          

        

      

       

      
        	
                10.

              	
                On
      a monthly basis, ODJFS will provide MCPs with an electronic Provider
      Master File containing all the Ohio Medicaid fee-for-service providers,
      which includes their Medicaid Provider Number, as well as all providers
      who have been assigned a provider reporting number for current encounter
      data purposes.  This file also includes National Provider Identifier
      (NPI) information where applicable.


              


      

       

      
        	
                11.

              	
                It
      is the intent of ODJFS to utilize electronic commerce for many processes
      and procedures that are now limited by HIPAA privacy concerns to FAX,
      telephone, or hard copy.  The use of TLS will mean that private
      health information (PHI) and the identification of consumers as Medicaid
      recipients can be shared between ODJFS and the contracting MCPs via e-mail
      such as reports, copies of letters, forms, hospital claims, discharge
      records, general discussions of member-specific information,
      etc.  ODJFS may revise data/information exchange policies and
      procedures for many functions that are now restricted to FAX, telephone,
      and hard copy, including, but not limited to, monthly membership and
      premium payment reconciliation requests, newborn reporting, Just Cause
      disenrollment requests, information requests etc. (as specified in
      Appendix C).

              


      

      


      
        	
                12.

              	
                ODJFS
      will immediately report to Center for Medicare and Medicaid Services (CMS)
      any breach in privacy or security that compromises protected health
      information (PHI), when reported by the MCP or ODJFS
      staff.

              


      

      


      13.           Service Area
Designation

       

      Membership
in a service area is mandatory unless ODJFS approves membership in the service
area for consumer initiated selections only. It is ODJFS’ current intention
to implement a mandatory managed care program in service areas wherever choice
and capacity allow and the criteria in 42 CFR 438.50(a) are met.

       

      14.           Consumer
information

      


      
        	
                 
      

              	
                a.

              	
                ODJFS
      or its delegated entity will provide membership notices, informational
      materials, and instructional materials relating to members and eligible
      individuals in a manner and format that may be easily understood. At least
      annually, ODJFS or designee will provide MCP eligible individuals,
      including current MCP members, with a Consumer Guide. The Consumer Guide
      will describe the managed  care program and include information
      on the MCP options in the service area and
      other  information  regarding the managed care program
      as specified in 42 CFR 438.10.

              


      

      


      
        	
                 
      

              	
                b.

              	
                ODJFS
      will notify members or ask MCPs to notify members about significant
      changes affecting contractual requirements, member services or access to
      providers.

              


      

      


      
        	
                 
      

              	
                c.

              	
                If
      an MCP elects not to provide, reimburse, or cover a counseling service or
      referral service due to an objection to the service on moral or religious
      grounds, ODJFS will provide coverage and reimbursement for these services
      for the MCP’s members.  ODJFS will provide information on what
      services the MCP will not cover and how and where the MCP’s members may
      obtain these services in the applicable Consumer
  Guides.

              


      

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
D

            Covered
Families and Children (CFC) population  

          

        

      

       

      15.           Membership Selection and
Premium Payment

       

      
        	
                 
      

              	
                a.

              	
                The
      managed care enrollment center (MCEC):  The ODJFS-contracted
      MCEC will provide unbiased education, selection services, and community
      outreach for the Medicaid managed care program.  The MCEC shall
      operate a statewide toll-free telephone center to assist eligible
      individuals in selecting an MCP or choosing a health care delivery
      option.

              


      

      


      
        	
                 
      

              	
                The
      MCEC shall distribute the most current
      Consumer Guide that includes the managed care program information as
      specified in 42 CFR 438.10, as well as ODJFS prior-approved MCP materials,
      such as solicitation brochures and provider directories, to consumers who
      request additional materials.

              


      

      


      
        	
                 
      

              	
                b.

              	
                Auto-Assignment
      Limitations – In order to ensure market and program stability,
      ODJFS may limit an MCP’s auto-assignments if they meet any of the
      following enrollment thresholds:

              


      

      


      
        	
                 
      

              	
                ·

              	
                55%
      of the statewide Covered Families and Children (CFC) eligible population;
      and/or

              


      

      
        	
                 
      

              	
                ·

              	
                70%
      of the CFC eligibles in any region with two MCPs;
  and/or

              


      

      
        	
                 
      

              	
                ·

              	
                55%
      of the CFC eligibles in any region with three
  MCPs

              


      

      


      Once an
MCP meets one of these enrollment thresholds, the MCP will only be permitted to
receive the additional new membership (in the region or statewide, as
applicable) through: (1) consumer-initiated enrollment; and (2)
auto-assignments which are based on previous enrollment in that MCP or an
historical provider relationship with a provider who is not on the panel of any
other MCP in that region. In the event that an MCP in a region meets one or more
of these enrollment thresholds, ODJFS, in their sole discretion, may not impose
the auto-assignment limitation and auto-assign members to the MCPs in that
region as ODJFS deems appropriate.

      


      
        	
                 
      

              	
                c.

              	
                Performance
      Based Auto-Assignments – Consumers who do not voluntarily select an MCP or
      are not auto-assigned to an MCP based on previous enrollment in that
      MC or an historical provider relationship with a provider who is not on
      the panel of another MCP in that region, will be auto-assigned based on
      the MCP performance using the following performance rating
      system:

              


      

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
D

            Covered
Families and Children (CFC) population  

          

        

      

       

      MCPs will be scored based on the
following ten measures:

      


      
        	
                 
      

              	
                i.

              	
                MCP
      Consumer Call Center  (see Appendix
C)

              


      

      
        	
                 
      

              	
                –

              	
                Average
      Speed of Answer

              


      

      
        	
                 
      

              	
                –

              	
                Abandonment
      Rate

              


      

      
        	
                 
      

              	
                –

              	
                Blockage
      rate

              


      

      
        	
                 
      

              	
                ii.

              	
                MCP
      Provider Call Center (measurement and standards will match those set for
      the MCP Consumer Call Center outlined in Appendix C. For a detailed
      description of the MCP Provider Call Center measure, see ODJFS Method for the MCP
      Provider Call Center
Measure.)

              


      

      
        	
              	
                –

              	
                Average
      Speed of Answer

              


        
          	
                   
      

                	
                  –

                	
                  Abandonment
      Rate

                


        

        
          	
                   
      

                	
                  –

                	
                  Blockage
      rate

                


        

      

       

      
      

      
      

      
      

      
        	
                 
      

              	
                iii.

              	
                MCP
      Prior Authorization (see OAC
5101:3-26-03.1)

              


      

      
        	
                 
      

              	
                –

              	
                Average
      Time to Process Non-Pharmacy
Requests

              


      

      
        	
                 
      

              	
                –

              	
                Average
      Time to Process Pharmacy Requests

              


      

      
        	
                 
      

              	
                iv.

              	
                Prompt
      Payment of Claims (see Appendix J)

              


      

      
        	
                 
      

              	
                –

              	
                Percentage
      of Claims Paid within 30 days

              


      

      
        	
                 
      

              	
                –

              	
                Percentage
      of Claims Paid within 90 days

              


      

       

      
        Each MCP
will receive a point for meeting the established standard.  If an MCP
meets the established standard for each measure, they will receive ten
points.  For each region, the MCP with the highest score will receive
the performance-based auto-assignments for the region.  If there is a
tie for the highest score, then each tying MCP will be considered equal in the
auto-assignment process.  Scoring will take place quarterly and
applied to the auto-assignment process once the results are
finalized.

        


        On a
regional basis, MCPs that have auto-assignment limitations in accordance with
15(b) do not qualify for performance-based auto-assignments unless (1) there are
two MCPs in the region, (2) the auto-assignment limited MCP received 10 points
and (3) the other MCP in the regional failed to receive 10 points.  In
this case, the MCP with the auto-assignment limitation shall receive
auto-assignments in the amount of 10% of the performance based auto-assignments
for every point the other MCP is below 10 points (i.e. if the other MCP has 7
points then the MCP would receive 30% (3 points * 10%)).

      

       

      
        	
                 
      

              	
                d.

              	
                Consumer Contact Record
      (CCR):  ODJFS or their designated entity shall forward
      CCRs to MCPs on no less than a weekly basis.  The CCRs are a
      record of each consumer-initiated MCP enrollment, change, or termination,
      and each MCEC initiated MCP assignment processed through the
      MCEC.  The CCR contains information that is not included on the
      monthly member roster.

              


      

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
D

            Covered
Families and Children (CFC) population  

          

        

      

       

      
        	
                 
      

              	
                e.

              	
                Monthly member roster
      (MR): ODJFS verifies managed care plan enrollment on a monthly
      basis via the monthly membership roster.  ODJFS or its
      designated entity provides a full member roster (F) and a change
      roster (C) via HIPAA 834
  compliant transactions.

              


      

      


      
        	
                 
      

              	
                f.

              	
                Monthly Premiums and
      Delivery Payments:  ODJFS will remit payment to the MCPs
      via an electronic funds transfer (EFT), or at the discretion of ODJFS, by
      paper warrant.

              


      

      


      
        	
                 
      

              	
                g.

              	
                Remittance
      Advice:  ODJFS will confirm all premium payments and
      delivery   payments paid to the MCP during the month via a
      monthly remittance advice (RA), which is sent to the MCP the week
      following state cut-off.  ODJFS or its designated entity
      provides a record of each payment via HIPAA 820 compliant
      transactions.

              


      

       

      
        	
                 
      

              	
                h.

              	
                MCP Reconciliation
      Assistance:  ODJFS will work with an MCP-designated
      contact(s) to resolve the MCP’s member and newborn eligibility inquiries,
      premium and delivery payment inquiries/discrepancies and to review/approve
      hospital deferment requests.

              


      

       

      16.           ODJFS
will make available a website which includes current program
information.

      


      
        	
                17.

              	
                ODJFS
      will regularly provide information to MCPs regarding different aspects of
      MCP performance including, but not limited to, information on
      MCP-specific and statewide external quality review organization surveys,
      focused clinical quality of care studies, consumer satisfaction surveys
      and provider profiles.

              


      

      


      18.           ODJFS
will periodically review a random sample of online and printed directories to
assess whether MCP information is both accessible and updated.

      


      19.           Communications

       

      a.           ODJFS/BMHC: The
Bureau of Managed Health Care (BMHC) is responsible for the oversight of the
MCPs’ provider agreements with ODJFS.Within the BMHC, a specific Contract
Administrator (CA) has been assigned to each MCP.  Unless expressly
directed otherwise, MCPs shall first contact their designated CA for
questions/assistance related to Medicaid and/or the MCP’s program requirements
/responsibilities. If their CA is not available and the MCP needs immediate
assistance, MCP staff should request to speak to a supervisor within the
Contract Administration Section.  MCPs should take all necessary and
appropriate steps to ensure
all MCP staff are aware of, and follow, this communication process.


       

      b.           ODJFS
contracting-entities:  ODJFS-contracting entities should never
be contacted by the MCPs unless the MCPs have been specifically instructed to
contact the ODJFS contracting entity directly.

       

      c.           MCP delegated
entities: In that MCPs are ultimately responsible for meeting program
requirements, the BMHC will not discuss MCP issues with the MCPs’ delegated
entities unless the applicable MCP is also participating in the
discussion.  MCP delegated entities, with the applicable MCP
participating, should only communicate with the specific CA assigned to that
MCP.

       

       

      


      
        
          
             


          

          
            5 


            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      
        APPENDIX
E

      

      
        RATE
METHODOLOGY

      

      
        CFC
ELIGIBLE POPULATION

      

      
         

      

      FINAL and
CONFIDENTIAL


       

      
        Chase
Center/Circle

        111
Monument Circle

        Suite
601 Indianapolis,
IN 46204-5128

        USA

        Tel    +1
317 638 1000
Fax   +1317 639
1001

        mllliman.com

      

      
        June
5, 2008

      

      
         

         

         

        Mr.
Jon Barley, Ph.D., Bureau Chief

      

      
        Bureau
of Managed Health Care

      

      
        Ohio
Department of Job and Family Services

      

      
        Lazarus
Building

      

      
        50
West Town St., Suite 400

      

      
        Columbus,
OH 43215

      

      
         

      

      
        
          	
                  RE:

                	
                  CAPITATION
      RATE CERTIFICATION - COVERED FAMILIES AND CHILDREN (CFC) July
      1, 2008 TO
      DECEMBER 31,
2008

                


        

      

      
         

      

      
        Dear
Jon:

      

      
         

      

      
        Milliman,
Inc. (Milliman) was retained by the State of Ohio, Department of Job and Family
Services (ODJFS) to develop the calendar year (CV) 2008 actuarially sound
capitation rates for the Covered Families and Children (CFC) Risk Based Managed
Care (RBMC) program. This letter provides the revised capitation rates to be
effective
from July 1,
2008 to
December 31,
2008. The revisions are a result of specific policy changes effective subsequent
to the development of the CY 2008 capitation rates.

      

      
         

      

      
        LIMITATIONS

      

      
        The
information contained in this letter, including the enclosures, has been
prepared for the State of Ohio, Department of Job and Family Services and their
consultants and advisors, it is our
understanding that the information contained in this letter may be utilized in a
public document. To the extent that the information contained in this letter is
provided to third parties, the letter should be distributed
in its entirety. Any user of the data must possess a certain level of expertise
in actuarial science and healthcare modeling so as not to misinterpret the data
presented.

         

      

      
        Milliman
makes no representations or warranties regarding the contents of this letter to
third parties, Likewise, third parties are instructed that they are to place no
reliance upon this letter prepared for ODJFS by Milliman that would result in
the creation of any duty or. liability under any theory of law by Milliman or
its employees to third parties.  Other parties receiving this letter must
rely upon
their own experts in drawing conclusions about the capitation rates,
assumptions, and trends.

         

        The information
contained in this letter was prepared as documentation of the- actuarially sound
capitation rates for Medicaid managed care organization health plans in the
State of Ohio. The information may not be appropriate for any other
purpose.

      

      


      
        
          
             


          

          
            1

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      EXECUTIVE
SUMMARY

      
         

      

      
        The
calendar year (CY) 2008 capitation rates for the Covered Families and Children
(CFC) Risk
Based Managed Care (R.BMC) program were revised for the period of July 1, 2008
to December 31, 2008. The revisions are a result of specific policy changes
effective subsequent to the development of the CY 2008 capitation rates. The
base data and actuarial assumptions underlying the CY 2008
capitation rates remain unchanged from the December 4, 2007 rate
certification and data book.

      

      
         

      

      
        Table 1 summarizes the current (January to
June 2008) and the revised (July to December 2008) capitation rate
expenditures as well as the
percentage changes by region on a composite all rate group
basis.

      

      
        Table
1

      

      
        STATE
OF OHIO

      

      
        DEPARTMENT
OF JOB AND FAMILY SERVICES

      

      
        COVERED
FAMILIES AND CHILDREN

      

      
        Capitation
Comparison - Aggregate Expenditures

      

      
        ($
millions)

      

       

      
        	
                
                  Region

                

              	 	
                
                  Jan
      – Jun

                

                
                  2008

                

              	 	 	
                
                  Jul
      – Dec

                

                
                  2008

                

              	 	 	
                
                  Expenditure

                

                
                  Change

                

              	 	 	
                
                  Percentage
      Change

                

              	 
	
                
                  Central

                

              	 	$	300.7	 	 	$	316.4	 	 	$	15.8	 	 	 	5.2	%
	
                
                  East
      Central

                

              	 	$	163.3	 	 	$	171.9	 	 	$	8.6	 	 	 	5.3	%
	
                
                  Northeast

                

              	 	$	270.0	 	 	$	283.8	 	 	$	13.8	 	 	 	5.1	%
	
                
                  Northeast
      Central

                

              	 	$	76.8	 	 	$	80.8	 	 	$	4.0	 	 	 	5.2	%
	
                
                  Northwest

                

              	 	$	156.9	 	 	$	165.4	 	 	$	8.5	 	 	 	5.4	%
	
                
                  Southeast

                

              	 	$	104.8	 	 	$	110.4	 	 	$	5.6	 	 	 	5.3	%
	
                
                  Southwest

                

              	 	$	197.5	 	 	$	207.0	 	 	$	9.5	 	 	 	4.8	%
	
                
                  West
      Central

                

              	 	$	132.1	 	 	$	139.2	 	 	$	7.1	 	 	 	5.4	%
	 	 
	
                
                  Statewide
      Composite

                

              	 	$	1,402.1	 	 	$	1,475.0	 	 	$	72.9	 	 	
                
                  5.2% |

                

              	 


      

      
         

      

      
        Note:
Values have been rounded

      

      
        

          
            
               


            

            
              2

              
                

              

            

            
              
                Appendix
E

                Covered
Families and Children (CFC) population   


              

            

          

        

         

      

      
        In aggregate, the July to
December 2008 capitation rates will result in a
5.2% increase relative to the
current January to June 2008 capitation rates.  The
composite rate increase reflects assumed health plan enrollment consistent with the
previously projected CY 2008 estimates.   Additionally, the
expenditure estimates assume equal distribution of member months and deliveries
throughout CY 2008.

      

      
         

      

      
        Enclosure
1 provides the current and proposed capitation rates and expenditures for each
rate group and geographic region as well as on a statewide composite
basis.

      

      
        Enclosure
2 contains the actuarial certification regarding the actuarial soundness of the
capitation rates.

      

      
         

      

      
        DETAILS
OF PROGRAM CHANGES

      

      
         

      

      
        The
capitation rates for the CFC program were revised for the period of July 1, 2008
to December 31, 2008. The
revisions are a result of specific program changes effective subsequent to the
development of the CY 2008 capitation rates. Table 2 summarizes the changes that
were reflected in the capitation rate change to be effective July 1,
2008.

      

      


      
        Table
2

      

      
        STATE
OF OHIO

      

      
        DEPARTMENT
OF JOB AND FAMILY SERVICES

      

      
        COVERED
FAMILIES AND CHILDREN

      

      
        Prospective
Program Adjustments

         

      

      
        	
                
                  Program

                

                
                  Adjustment

                

              	
                
                  Effective

                

                
                  Date

                

              	
                
                  Service
      Category(s)

                

              	
                
                  Rate

                

                
                  Groups

                

              	
                
                  Adjustment
      Factor

                

              	
                
                  Estimated
      Aggregate Impact

                

              
	
                
                  Inpatient
      Capital Component

                

              	
                
                  1/1/2008

                

              	
                
                  Inpatient
      (excl.
      Nursing Facility)

                

              	
                
                  All
      Rate Groups (incl. Delivery)

                

              	
                
                  2.50%

                

              	
                
                  $11.5 M/
      0.8%

                

              
	
                
                  Community
      Providers Fee Schedule Increase

                

              	
                
                  7/1/2008

                

              	
                
                  Community
      Based Provider Categories

                

              	
                
                  All
      Rate Groups (incl.
      Delivery)

                

              	
                
                  4.13%

                

              	
                
                  $25.7
      M/
      1.8%

                

              
	
                
                  Dental Benefit Restoration

                

              	
                
                  7/1/2008

                

              	
                
                  Dental

                

              	
                
                  HF M-19 to44

                

              	
                
                  30.24%

                

              	
                
                  $9.8
      M/ 0.7%

                

              
	 
      	 
      	 
      	
                
                  HF F-19 to 44

                

              	
                
                  34.16%

                

              	 
      
	 
      	 
      	 
      	
                
                  HF
      M/F -
      45 to 64

                

              	
                
                  30.18%

                

              	 
      
	 
      	 
      	 
      	
                
                  HST F- 19 to 64

                

              	
                
                  49.48%

                

              	 
      
	
                
                  CHIP
      III Expansion Revision

                

              	
                
                  1/1/2008

                

              	
                
                  All
      Service Categories

                

              	
                
                  HST M/F- 2 to 13

                

              	
                
                   

                  (0.34%)

                

              	
                
                  ($1.4) M/
      (0.1%)

                

              
	
                
                  HST M - 14 to
      18

                

              
	 
      	 
      	 
      	
                
                  HST F-14 to l8

                

              	 
      	 
      
	
                
                  Improved
      TPL Management Revision

                

              	
                
                  1/1/2008

                

              	
                
                  All
      Service Categories

                

              	
                
                  All Rate
      Groups (incl. Delivery)

                

              	
                
                  0.84%

                

              	
                
                  $11.5 M/
      .8%

                

              
	
                
                  Franchise
      Fee Increase

                

              	
                
                  7/1/2008

                

              	
                
                  All
      Service Categories

                

              	
                
                  All
      Rate Groups (incl. Delivery)

                

              	
                
                  1.06%

                

              	
                
                  $15.4 M/
      1.1%

                

              
	
                
                  Franchise
      Fee - Timing Adjustment

                

              	
                
                  7/1/2008

                

              	
                
                  All
      Service Categories

                

              	
                
                  Delivery

                

              	
                
                  0.42%

                

              	
                
                  $0.4
      M/
      <0.1%

                

              


      

    

    Note:
Estimated aggregate impact includes administrative cost and franchise fee
components (values have been rounded).

    
      


      
        
          
             


          

          
            3

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        Inpatient Capital
Component

      

      
         

      

      
        The
capital component of the CY 2008 DRG hospital payment rates was increased on
January 1,
2008. The changes are being reflected in the managed care capitation rates as it
is recognized that the majority of contracts held by the health plans reflect a
percentage of the base FFS reimbursement prior to annual capital settlements
with providers. As such, Milliman reviewed the impact of the capital changes
using a distribution of admissions and paid claims by provider appropriate for
the CFC managed care enrolled population.

      

      
         

      

      
        The
increase was not included in the capitation rates effective January 1, 2008 due to the
timing of this change. Milliman has included this adjustment into the capitation
rates to be effective from July 1, 2008 to December
31, 2008.
The adjustment reflects a retro-active payment for January to June 2008 as well
as a prospective adjustment for July to December 2008.

      

      
         

      

      
        Milliman
obtained the hospital capital rates for CY 2007 and CY 2008 by provider as well
as the distribution of paid claims and admissions by provider for SFY 2006. The
adjustment factor was calculated using the following
Methodology:

      

      
         

      

      
        Adjustment
Factor = [Admissions
SFY2006  X
(Capital CY2008 – Capital
CY2007)] /Total
Paid

      

      
        SFY2006

      

      
         

      

      
        Community
Provider Fee Schedule Update

      

      
         

      

      
        The
fee schedule used to reimburse FFS community providers was updated by ODJFS
effective July 1, 2008. The changes are being reflected in the managed care
capitation rates as it is recognized that the majority of contracts held by the
health plans reflect a percentage of the FFS reimbursement. As such, Milliman
reviewed the impact of the fee changes using a distribution of services and paid
claims appropriate for the CFC managed care enrolled
population.

      

      
         

      

      
        Milliman
obtained the fee schedule by procedure code and modifier code for the current
fees (prior to July 1, 2008) and the revised fees (post July 1, 2008) as well as
the distribution of paid claims and utilization counts for SFY 2006. The
adjustment factor was calculated using the following
Methodology:

      

      
         

      

      
        Adjustment
Factor = [Total
Paid SFY2006 X
(Fee Post 7 1 08 / Fee
Prior to 7 1 08)]
/ Total
Paid SFY2006 - 1

      

      
         

      

      
        Table
3 summarizes the impact of the community provider fee schedule update by
category of service.

      

      
         

      

       

      
        
          
             


          

          
            4

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        Table
3

      

      
        STATE
OF OHIO

      

      
        DEPARTMENT
OF JOB AND FAMILY SERVICES

      

      
        COVERED
FAMILIES AND CHILDREN

      

      
        Community
Provider Fee Adjustments

      

       

      
        	
                
                  Service
      Category

                

              	
                
                  Impact
      of Fee 

                  Changes

                   

                

              
	
                
                  Outpatient

                

              	 
	
                
                  Surgery/ASC

                

              	0.3%
	
                
                  Professional

                

              	 
	
                
                  Surgery

                

              	(1.2%)
	
                
                  Anesthesia

                

              	0.0%
	
                
                  Obstetrics

                

              	6.5%
	
                
                  Office
      Visits/Consults

                

              	14.0%
	
                
                  inpatient
      Visits

                

              	9.2%
	
                
                  Periodic
      Exams

                

              	5.7%
	
                
                  Emergency
      Room

                

              	6.7%
	
                
                  Immunizations
      & Injection

                

              	15.0%
	
                
                  Physical
      Medicine

                

              	3.2%
	
                
                  Miscellaneous
      Services

                

              	5.7%
	
                
                  Rad/Path/Lab

                

              	 
	
                
                  Radiology

                

              	(0.6%)
	
                
                  Path/Lab

                

              	0.3%
	
                
                  Other
      Benefits

                

              	 
	 Mental
      Health/Substance Abuse            	7.1 %
	
                
                  Dental

                

              	2.3%
	
                
                  Vision
      - Optometric

                

              	6.1%
	
                
                  Home
      Health

                

              	3.0%
	 Non-Emergent
      Transportation	2.3 %
	
                
                  Ambulance

                

              	2.1%
	
                
                  Supplies
      & DME

                

              	0.0%
	
                
                  Miscellaneous
      Services

                

              	2.9%


      

      
        Note:
Values have been rounded.

      

      
         

      

      
        
          
             


          

          
            5

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        
          
            Dental
Benefit Restoration

             

          

          Dental
benefits will be restored to the adult rate groups effective July 1, 2008. This
impact was calculated and included in previous drafts of the CY 2008 capitation
rates. However, the benefit restoration was delayed and,
as such, was not included in the final capitation rates effective January 1,
2008.

        

        
           

        

        
          The
adjustment factors summarized in Table 2 for the dental benefit restoration are
consistent with the previously provided amounts, with one exception. The impact
of pent-up
demand previously included was increased from 2% to 4%. This reflects that the
total of the pent-up demand is still assumed to occur; however, it will occur
over only half of the calendar year.

        

      

       

      
        CHIP
III Expansion

      

      
         

      

      
        The
capitation rates effective January 1, 2008 included an increase due to the
expansion of coverage to the CHIP program from 200% to 300% FPL. This expansion
has not begun as of this time and remains uncertain for the remainder of the
calendar year. As such, Milliman has included
an adjustment in the capitation rates effective for July to December 2008. The
adjustment reflects a retro-active adjustment for January to June 2008 as well
as a prospective adjustment for July to December 2008 to remove the total impact
of the CHIP
III expansion from the entire calendar year.

      

      
         

      

      
        The
adjustment factor was calculated by removing the increase from the current
rates

      

      
        [1
/ (1+0.17%)] and retro-actively removing the
previously increased amount [1-0.17%].

      

      
        Milliman
and ODJFS will monitor the progress of the CHIP III expansion and may revise the
rates prior to CY 2009 should a material change occur.

      

      
         

      

      
        Improved
TPL Management

      

      
         

      

      
        The
capitation rates effective January 1, 2008 included a
reduction due to the anticipated improvements in the TPL data and information
that would allow for increased TPL collections and cost avoidance by the health
plans. The
planned improvements have been delayed until October 1, 2008. As such, Milliman
has included an adjustment in the capitation rates effective for July to
December 2008. The adjustment reflects a retro-active payment for January to
June 2008 as well as a prospective adjustment for July to September 2008 to
remove the value of the TPL improvements from the first nine months of calendar
year 2008. The adjustment will be applied to the payments for July to December
2008.

      

      
         

      

      
        The
adjustment factor was calculated by modifying the reduction from the current
rates and retro-actively restoring the
previously reduced amount [(l+.28%) / (1 -.55%)].

      

      
         

      

      
        
          
             


          

          
            6

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        
          Franchise
Fee Increase

        

      

      
         

      

      
        The
franchise fee amount was increased
from 4.5% to 5.5% of the capitation rate effective July 1, 2008. This adjustment
was applied by removing the current franchise fee percent and applying the
revised franchise fee percent for all regions and rate
groups.

      

      
         

      

      
        Franchise
Fee - Timing
Adjustment

      

      
         

      

      
        The
revision of the franchise fee amount creates an exposure issue for the health
plans as the timing and methodology of the capitation payments differs from the
collection of the fees by the State. Franchise fee payments included in the
capitation rates are paid based on the incurred dates of service for the
Delivery and Non-Delivery rate groups. Collections of the franchise fee by the State are
based on the date of payment-of the
capitation rate. As such, to the extent there is a lag in payment of the
capitation rate, there is an inherent mis-alignment of payment and collection of
the franchise fee. This issue only arises when a change in the franchise fee
percent occurs.

      

      
         

      

      
        Milliman reviewed the
lag time of capitation incurred periods to
capitation payment periods to estimate the impact of this change. For the
Non-Delivery rate groups, the capitation payments primarily occur on or 'before the service
month eliminating the impact of this change. For the Delivery rate group, the
capitation payments are paid with significant lag times, similar to the
lag found in FFS claims. As such, Milliman included an adjustment to the
Deliver)' payment for July to December 2008 to reflect this
change.

      

      
         

      

      
        Table
4 summarizes the percentage of deliver)' capitation payment amounts between
those paid prior to July 1, 2008 and those
paid after July 1, 2008. The
percentages reflect an average historical amount using a 12 month
completion factor estimate, after removing the highest and lowest
values.

      

       

      
        
          
             


          

          
            7

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        Table
4

      

      
        STATE
OF OHIO

      

      
        DEPARTMENT
OF JOB AND FAMILY SERVICES

      

      
        COVERED
FAMILIES AND CHILDREN

      

      
        Delivery
Rate Group - Lag Factors

      

       

      
        	
                
                  Delivery Month

                

              	
                
                  Percentage
      Paid Prior to July 1, 2008

                

              	
                
                  Percentage Paid
      After July 1, 2008

                

              
	
                
                  July
      2007

                

              	
                
                  99.9%

                

              	
                
                  0.1%

                

              
	
                
                  August
      2007

                

              	
                
                  99.7%

                

              	
                
                  0.3%

                

              
	
                
                  September
      2007

                

              	
                
                  99.1%

                

              	
                
                  0.9%

                

              
	
                
                  October
      2007

                

              	
                
                  98.7%

                

              	
                
                  1.3%

                

              
	
                
                  November
      2007

                

              	
                
                  98.3%

                

              	
                
                  1.7%

                

              
	
                
                  December
      2007

                

              	
                
                  97.5%

                

              	
                
                  2.5%

                

              
	
                
                  January
      2008

                

              	
                
                  96.2%

                

              	
                
                  3.8%

                

              
	
                
                  February
      2008

                

              	
                
                  93.9%

                

              	
                
                  6.1%

                

              
	
                
                  March
      2008

                

              	
                
                  86.8%

                

              	
                
                  13.2%

                

              
	
                
                  April
      2008

                

              	
                
                  59.0%

                

              	
                
                  41.0%

                

              
	
                
                  May
      2008

                

              	
                
                  17.9%

                

              	
                
                  82.1%

                

              
	
                
                  June
      2008

                

              	
                
                  0.0%

                

              	
                
                  100.0%

                

              


      

      
        Note:
Values have been rounded.

      

      
         

      

      
        If you have any
questions regarding the enclosed information, please do not hesitate to contact
me at

      

      
        (317)
524-3512.

      

      
        Sincerely,

      

      
         

      

      
        Robert
M. Damler, FSA,
MAAA

      

      
        Principal
and Consulting Actuary

      

      
         

      

      
         

      

      
        RMD/1rb

      

      
        Enclosures

      

       

      
        
          
             


          

          
            8

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        ENCLOSURE
1

      

      
         

      

      
        State of Ohio

      

      
        Department of Job
and Family Services

      

      
        Capitation
Rate Comparison - CFC

         

      

      
        
          
            	
                    
                      Region

                    

                  	
                    
                      Rate
      Group

                    

                  	 	
                    
                      Projected

                    

                    
                      Jul
      - Dec 2008

                    

                    
                      MMs/Deliveries

                    

                  	 	 	
                    
                      Jan-Jun

                    

                    
                      2008

                    

                    
                      Cap
      Rate

                    

                  	 	 	
                    
                      Jan-Jun
      2008

                    

                    
                      Expenditures

                    

                  	 	 	
                    
                      Jul-Dec
      2008

                    

                    
                      Cap
      Rate

                    

                  	 	 	
                    
                      Jul-Dec
      2008

                    

                    
                      Expenditures

                    

                  	 	 	
                    
                      % Change

                    

                  	 	 	
                    
                      $
      Change

                    

                  	 
	
                    
                      Central

                    

                  	
                    
                      HF/HST
      <1 M+F

                    

                  	 	 	101,760	 	 	$	568.17	 	 	$	57,816,695	 	 	$	596.95	 	 	$	60,745,334	 	 	 	5.1	%	 	$	2,928,638	 
	
                    
                      Central

                    

                  	
                    
                      HF/HST
      1 M+F

                    

                  	 	 	79,228	 	 	 	146.51	 	 	 	11,607,694	 	 	 	154.00	 	 	 	12,201,112	 	 	 	5.1	%	 	 	593,418	 
	
                    
                      Central

                    

                  	
                    
                      HF/HST
      2-13 M+F

                    

                  	 	 	613,230	 	 	 	99.10	 	 	 	60,771,093	 	 	 	103.23	 	 	 	63,303,733	 	 	 	4.2	%	 	 	2,532,640	 
	
                    
                      Central   

                    

                  	
                    
                      HF/HST
      14-18 F

                    

                  	 	 	81,608	 	 	 	165.19	 	 	 	13,480,826	 	 	 	172.11	 	 	 	14,045,553	 	 	 	4.2	%	 	 	564,727	 
	
                    
                      Central

                    

                  	
                    
                      HF/HST
      14-18 M

                    

                  	 	 	73,398	 	 	 	118.54	 	 	 	8,700,599	 	 	 	122.99	 	 	 	9,027,220	 	 	 	3.8	%	 	 	326,621	 
	
                    
                      Central

                    

                  	
                    
                      HF
      19-44
      F

                    

                  	 	 	275,119	 	 	 	304.31	 	 	 	83,721,311	 	 	 	322.46	 	 	 	88,714,712	 	 	 	6.0	%	 	 	4,993,401	 
	
                    
                      Central

                    

                  	
                    
                      HF
      19-44
      M

                    

                  	 	 	84,102	 	 	 	198.75	 	 	 	16,715,273	 	 	 	211.71	 	 	 	17,805,234	 	 	 	6.5	%	 	 	1,089,962	 
	
                    
                      Central

                    

                  	
                    
                      HF45+M+F

                    

                  	 	 	32,705	 	 	 	485.77	 	 	 	15,886,865	 	 	 	509.32	 	 	 	16,657,056	 	 	 	4.8	%	 	 	770,191	 
	
                    
                      Central

                    

                  	
                    
                      HST 19-64 F

                    

                  	 	 	30,857	 	 	 	376.25	 	 	 	11,609,758	 	 	 	401.72	 	 	 	12,395,673	 	 	 	6.8	%	 	 	785,915	 
	
                    
                      Central

                    

                  	
                    
                      Composite
      Non-Delivery

                    

                  	 	 	1,372,005	 	 	 	204.31	 	 	 	280,310,113	 	 	 	214.94	 	 	 	294,895,626	 	 	 	5.2	%	 	 	14,585,513	 
	
                    
                      Central

                    

                  	
                    
                      Delivery
      CFC

                    

                  	 	 	5,427	 	 	 	3,754.26	 	 	 	20,374,369	 	 	 	3,969.58	 	 	 	21,542,911	 	 	 	5.7	%	 	 	1,168,542	 
	
                    
                      Central

                    

                  	
                    
                      Composite
      with Delivery

                    

                  	 	 	1,372,005	 	 	$	219.16	 	 	$	300,684,482	 	 	$	230.64	 	 	$	316,438,537	 	 	 	5.2	%	 	$	15,754,055	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF/HST
      <1 M+F

                    

                  	 	 	50,472	 	 	$	553.95	 	 	$	27,958,687	 	 	$	582.04	 	 	$	29,376,432	 	 	 	5.1	%	 	$	1,417,744	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF/HST
      1 M+F

                    

                  	 	 	37,738	 	 	 	142.85	 	 	 	5,390,873	 	 	 	150.15	 	 	 	5,666,361	 	 	 	5.1	%	 	 	275,487	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF/HST
      2-13 M+F

                    

                  	 	 	334,892	 	 	 	96.62	 	 	 	32,357,265	 	 	 	100.66	 	 	 	33,710,229	 	 	 	4.2	%	 	 	1,352,964	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF/HST
      14-18 F

                    

                  	 	 	48,233	 	 	 	161.06	 	 	 	7,768,326	 	 	 	167.81	 	 	 	8,093,896	 	 	 	4.2	%	 	 	325,569	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF/HST
      14-18 M

                    

                  	 	 	44,187	 	 	 	115.57	 	 	 	5,106,692	 	 	 	119.92	 	 	 	5,298,905	 	 	 	3.8	%	 	 	192,213	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF 19-44 F

                    

                  	 	 	160,491	 	 	 	296.69	 	 	 	47,616,075	 	 	 	314.41	 	 	 	50,459,975	 	 	 	6.0	%	 	 	2,843,901	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF
      19-44
      M

                    

                  	 	 	45,442	 	 	 	193.78	 	 	 	8,805,654	 	 	 	206.42	 	 	 	9,380,034	 	 	 	6.5	%	 	 	574,381	 
	
                    
                      East
      Central

                    

                  	
                    
                      HF 45+M+F

                    

                  	 	 	19,782	 	 	 	473.60	 	 	 	9,368,518	 	 	 	496.60	 	 	 	9,823,493	 	 	 	4.9	%	 	 	454,974	 
	
                    
                      East
      Central

                    

                  	
                    
                      HST 19-64 F

                    

                  	 	 	16,944	 	 	 	366.84	 	 	 	6,215,737	 	 	 	391.69	 	 	 	6,636,795	 	 	 	6.8	%	 	 	421,058	 
	
                    
                      East
      Central

                    

                  	
                    
                      Composite
      Non-Delivery

                    

                  	 	 	758,179	 	 	 	198.62	 	 	 	150,587.828	 	 	 	208.98	 	 	 	158,446,120	 	 	 	5.2	%	 	 	7,858,292	 
	
                    
                      East
      Central

                    

                  	
                    
                      Delivery
      CFC

                    

                  	 	 	3,193	 	 	 	3,990.44	 	 	 	12,741,475	 	 	 	4,217.02	 	 	 	13,464,945	 	 	 	5.7	%	 	 	723,470	 
	
                    
                      East
      Central

                    

                  	
                    
                      Composite
      with
      Delivery

                    

                  	 	 	758,179	 	 	$	215.42	 	 	$	163,329,303	 	 	$	226.74	 	 	$	171,911,065	 	 	 	5.3	%	 	$	8,581,762	 
	
                    
                      Northeast

                    

                  	
                    
                      HF/HST
      <l M+F

                    

                  	 	 	81,194	 	 	$	537.65	 	 	$	43,653,685	 	 	$	564.33	 	 	$	45,819,928	 	 	 	5.0	%	 	$	2,166,243	 
	
                    
                      Northeast

                    

                  	
                    
                      HF/HST
      1 M+F

                    

                  	 	 	65,469	 	 	 	138.65	 	 	 	9,077,208	 	 	 	145.58	 	 	 	9,530,904	 	 	 	5.0	%	 	 	453,697	 
	
                    
                      Northeast

                    

                  	
                    
                      HF/HST
      2-13 M+F

                    

                  	 	 	580,015	 	 	 	93.78	 	 	 	54,393,760	 	 	 	97.58	 	 	 	56,597,815	 	 	 	4.1	%	 	 	2,204,055	 
	
                    
                      Northeast

                    

                  	
                    
                      HF/HST
      14-18 F

                    

                  	 	 	90,422	 	 	 	156.32	 	 	 	14,134,689	 	 	 	162.70	 	 	
                    
                      14,711,578

                    

                  	 	 	 	4.1	%	 	 	576,889	 
	
                    
                      Northeast

                    

                  	
                    
                      HF/HST
      14-18 M

                    

                  	 	 	82,194	 	 	 	112.18	 	 	 	9,220,523	 	 	 	116.25	 	 	 	9,555,053	 	 	 	3.6	%	 	 	334,530	 
	
                    
                      Northeast

                    

                  	
                    
                      HF
      19-44 F

                    

                  	 	 	280,510	 	 	 	287.97	 	 	 	80,778,321	 	 	 	304.84	 	 	 	85,510,516	 	 	 	5.9	%	 	 	4,732,195	 
	
                    
                      Northeast

                    

                  	
                    
                      HF 19-44
      M

                    

                  	 	 	59,915	 	 	 	188.08	 	 	 	11,268,813	 	 	 	200.14	 	 	 	11,991,388	 	 	 	6.4	%	 	 	722,575	 
	
                    
                      Northeast

                    

                  	
                    
                      HF
      45+ M+F

                    

                  	 	 	39,374	 	 	 	459.68	 	 	 	18,099,440	 	 	 	481.47	 	 	 	18,957,400	 	 	 	4.7	%	 	 	857,959	 
	
                    
                      Northeast

                    

                  	
                    
                      HST
      19-64 F

                    

                  	 	 	25,467	 	 	 	356.04	 	 	 	9,067,271	 	 	 	379.76	 	 	 	9,671,348	 	 	 	6.7	%.	 	 	604,077	 
	
                    
                      Northeast

                    

                  	
                    
                      Composite
      Non-Delivery

                    

                  	 	 	1,304,558	 	 	 	191.40	 	 	 	249,693,709	 	 	 	201.10	 	 	 	262,345,929•	 	 	 	5.1	%	 	 	12,652,220	 
	
                    
                      Northeast

                    

                  	
                    
                      Delivery
      CFC

                    

                  	 	 	4,936	 	 	 	4,105.75	 	 	 	20,263,929	 	 	 	4,343.69	 	 	 	21,438,282	 	 	 	5.8	%.	 	 	1,174,353	 
	
                    
                      Northeast

                    

                  	
                    
                      Composite
      with Delivery

                    

                  	 	 	1,304,558	 	 	$	206.93	 	 	$	269,957,638	 	 	$	217.53	 	 	$	283,784,211	 	 	 	5.1	%	 	$	13,826,573	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF/HST
      <1 M+F

                    

                  	 	 	21,399	 	 	$	580.71	 	 	$	12,426,613	 	 	$	610.12	 	 	$	13,055,958	 	 	 	5.1	%	 	$	629,345	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF/HST
      1 M+F

                    

                  	 	 	16,275	 	 	 	149.76	 	 	 	2,437,344	 	 	 	157.39	 	 	 	2,561,522	 	 	 	5.1	%	 	 	124,178	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF/HST
      2-13 M+F

                    

                  	 	 	153,239	 	 	 	101.29	 	 	 	15,521,528	 	 	 	105.49	 	 	 	16,165,129	 	 	 	4.1	%	 	 	643,602	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF/HST
      14-18
      F

                    

                  	 	 	23,927	 	 	 	168.84	 	 	 	4,039,750	 	 	 	175.90	 	 	 	4,208,671	 	 	 	4.2	%	 	 	168,921	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF/HST
      14-18 M

                    

                  	 	 	22,188	 	 	 	121.16	 	 	 	2,688,298	 	 	 	125.70	 	 	 	2,789,032	 	 	 	3.7	%,	 	 	100,734	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF
      19-44 F

                    

                  	 	 	72,662	 	 	 	311.04	 	 	 	22,600,633	 	 	 	329.58	 	 	 	23,947,777	 	 	 	6.0	%	 	 	1,347,144	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF
      19-44
      M

                    

                  	 	 	20,846	 	 	 	203.14	 	 	 	4,234,656	 	 	 	216.39	 	 	 	4,510,866	 	 	 	6.5	%	 	 	276,210	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HF
      45+ M+F

                    

                  	 	 	9,292	 	 	 	496.49	 	 	 	4,613,137	 	 	 	520.55	 	 	 	4,836,690	 	 	 	4.8	%	 	 	223,553	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      HST
      19-64 F

                    

                  	 	 	7,043	 	 	 	384.55	 	 	 	2,708,193	 	 	 	410.58	 	 	 	2,891,510	 	 	 	6.8	%	 	 	183,316	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      Composite Non-Delivery

                    

                  	 	 	346,869	 	 	 	205.47	 	 	 	71,270,153	 	 	 	216.13	 	 	 	74,967,156	 	 	 	5.2	%	 	 	3,697,003	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      Delivery
      CFC

                    

                  	 	 	1,342	 	 	 	4,113.88	 	 	 	5,518,770	 	 	 	4,351.17	 	 	 	5,837,095	 	 	 	5.8	%	 	 	318,325	 
	
                    
                      Northeast
      Central

                    

                  	
                    
                      Composite
      with Delivery

                    

                  	 	 	346,869	 	 	$	221.38	 	 	
                    
                      $           
      76,788,923

                    

                  	 	 	$	232.95	 	 	$	80,804,250	 	 	 	5.2	%	 	$	4,015,327	 
	
                    
                      Northwest

                    

                  	
                    
                      HF/HST
      <1 M+F

                    

                  	 	 	51,535	 	 	$	565.81	 	 	$	29,159,018	 	 	$	595.46	 	 	$	30,687,031	 	 	 	5.2	%	 	$	1,528,013	 
	
                    
                      Northwest

                    

                  	
                    
                      HF/HST
      1 M+F

                    

                  	 	 	38,387	 	 	 	145.91	 	 	 	5,600,974	 	 	 	153.61	 	 	 	5,896,550	 	 	 	5.3	%	 	 	295,576	 
	
                    
                      Northwest

                    

                  	
                    
                      HF/HST 2-13
      M+F

                    

                  	 	 	313,927	 	 	 	98.69	 	 	 	30,981,456	 	 	 	102.96	 	 	 	32,321,924	 	 	 	4.3	%	 	 	1,340,468	 
	
                    
                      Northwest

                    

                  	
                    
                      HF/HST
      14-18 F

                    

                  	 	 	45,514	 	 	 	164.51	 	 	 	7,487,508	 	 	 	171.68	 	 	 	7,813,844	 	 	 	4.4	%	 	 	326,335	 
	
                    
                      Northwest

                    

                  	
                    
                      HF/HST
      14-18
      M

                    

                  	 	 	41,124	 	 	 	118.04	 	 	 	4,854,218	 	 	 	122.68	 	 	 	5,045,031	 	 	 	3.9	%	 	 	190,813	 
	
                    
                      Northwest

                    

                  	
                    
                      HF
      19-44
      F

                    

                  	 	 	145,022	 	 	 	303.05	 	 	 	43,948,917	 	 	 	321.64	 	 	 	46,644,876	 	 	 	6.1	%	 	 	2,695,959	 
	
                    
                      Northwest

                    

                  	
                    
                      HF
      19-44 M

                    

                  	 	 	44,005	 	 	 	197.94	 	 	 	8,710,350	 	 	 	211.19	 	 	 	9,293,416	 	 	 	6.7	%	 	 	583,066	 
	
                    
                      Northwest

                    

                  	
                    
                      HF
      45+ M+F

                    

                  	 	 	16,482	 	 	 	483.76	 	 	 	7,973,090	 	 	 	508.04	 	 	 	8,373,261	 	 	 	5.0	%	 	 	400,171	 
	
                    
                      Northwest

                    

                  	
                    
                      HST
      19-64
      F

                    

                  	 	 	18,071	 	 	 	374.69	 	 	 	6,771,023	 	 	 	400.72	 	 	 	7,241,411	 	 	 	6.9	%	 	 	470,388	 
	
                    
                      Northwest

                    

                  	
                    
                      Composite
      Non-Delivery

                    

                  	 	 	714.066	 	 	 	203.74	 	 	 	145,486,555	 	 	 	214.71	 	 	 	153,317,344	 	 	 	5.4	%	 	 	7,830,790	 
	
                    
                      Northwest

                    

                  	
                    
                      Delivery*
      CFC

                    

                  	 	 	3,040	 	 	 	3,768.39	 	 	 	 	 	 	 	3,981.10	 	 	 	12,102,544	 	 	 	5.6	%	 	 	646,638	 
	
                    
                      Northwest

                    

                  	
                    
                      Composite
      with Delivery

                    

                  	 	 	714,066	 	 	$	219.79	 	 	$	156,942,460	 	 	$	231.66	 	 	$	165,419,888	 	 	 	5.4	%	 	$	8,477,428	 


          


          
            
               


            

            
              9

              
                

              

            

            
              
                Appendix
E

                Covered
Families and Children (CFC) population   


              

            

          

        

      

      
         

        State of Ohio

        
          Department of Job
and Family Services

        

        
          Capitation
Rate Comparison - CFC

        

      

       

      
        
          	
                  
                    Region

                  

                	
                  
                    Rate
      Group

                  

                  
                     

                  

                	 	
                  
                    Projected

                  

                  
                    Jul-Dec 2008

                  

                  
                    MMs/Deliveries

                  

                	 	 	
                  
                    Jan
      - Jun

                  

                  
                    2008

                  

                  
                    Cap
      Rate

                  

                	 	 	
                  
                    Jan-Jun
      2008

                  

                  
                    Expenditures

                  

                	 	 	
                  
                    Jul
      – Dec 2008

                  

                  
                    Cap
      Rate

                  

                  
                  

                	 	 	
                  
                    Jul
      - Dec 2008

                  

                  
                    Expenditures

                  

                	 	 	
                  
                    %
      Change

                  

                	 	 	
                  
                    $
      Change

                  

                	 
	
                  
                    Southeast

                  

                	
                  
                    HF/HST <l M+F

                  

                	 	 	27,057	 	 	$	575.04	 	 	$	15,558,570	 	 	$	604.37	 	 	$	16,352,137	 	 	 	5.1	%	 	$	793,567	 
	
                  
                    Southeast

                  

                	
                  
                    HF/HST
      1 M+F

                  

                	 	 	22,178	 	 	 	148.29	 	 	 	3,288,701	 	 	 	155.90	 	 	 	3,457,472	 	 	 	5.1	%	 	 	168,771	 
	
                  
                    Southeast

                  

                	
                  
                    HF/HST 2-13 M+F

                  

                	 	 	202,856	 	 	 	100.30	 	 	 	20,346,407	 	 	 	104.51	 	 	 	21,200,428	 	 	 	4.2	%	 	 	854,022	 
	
                  
                    Southeast

                  

                	
                  
                    HF/HST
      14-18
      F

                  

                	 	 	30,272	 	 	 	167.19	 	 	 	5,061,176	 	 	 	174.25	 	 	 	5,274,896	 	 	 	4.2	%	 	 	213,720	 
	
                  
                    Southeast

                  

                	
                  
                    HF/HST
      14-18 M

                  

                	 	 	28,111	 	 	 	119.98	 	 	 	3,372,698	 	 	 	124.52	 	 	 	3,500,319	 	 	 	3.8	%	 	 	127.622	 
	
                  
                    Southeast

                  

                	
                  
                    HF
      19-44
      F

                  

                	 	 	102,587	 	 	 	308.00	 	 	 	31,596,796	 	 	 	326.47	 	 	 	33,491,578	 	 	 	6.0	%	 	 	1,894,782	 
	
                  
                    Southeast

                  

                	
                  
                    HF 19-44
      M

                  

                	 	 	45,156	 	 	 	201.16	 	 	 	9,083,581	 	 	 	214.34	 	 	 	9,678,737	 	 	 	6.6	%	 	 	595,156	 
	
                  
                    Southeast

                  

                	
                  
                    HF
      45+ M+F

                  

                	 	 	13,518	 	 	 	491.63	 	 	 	6,645,854	 	 	 	515.65	 	 	 	6,970,557	 	 	 	4.9	%	 	 	324.702	 
	
                  
                    Southeast

                  

                	
                  
                    HST
      19-64 F

                  

                	 	 	9,472	 	 	 	380.81	 	 	 	3,606,842	 	 	 	406.72	 	 	 	3,852,248	 	 	 	6.8	%	 	 	245,407	 
	
                  
                    Southeast

                  

                	
                  
                    Composite
      Non-Delivery

                  

                	 	 	481,205	 	 	 	204.82	 	 	 	98,560,625	 	 	 	215.66	 	 	 	103,778,373	 	 	 	5.3	%	 	 	5,217,748	 
	
                  
                    Southeast

                  

                	
                  
                    Delivery
      CFC

                  

                	 	 	1,764	 	 	 	3,557.15	 	 	 	6,274,813	 	 	 	3,765.08	 	 	 	6,641,601	 	 	 	5.8	%	 	 	366,789	 
	
                  
                    Southeast

                  

                	
                  
                    Composite
      with Delivery

                  

                	 	 	481,205
      	 	 	$	217.86
      	 	 	$	104,835,437	 	 	$	229.47	 	 	$	110,419,974	 	 	 	5.3	%	 	$	5,584,537	 
	
                  
                    Southwest

                  

                	
                  
                    HF/HST <1
      M+F

                  

                	 	 	68,146	 	 	$	606.96	 	 	$	41,361,896	 	 	$	635.17	 	 	$	43,284,295	 	 	 	4.6	%	 	$	1,922,399	 
	
                  
                    Southwest

                  

                	
                  
                    HF/HST 1
      M+F

                  

                	 	 	49,201	 	 	 	156.52	 	 	 	7,700,862	 	 	 	163.85	 	 	 	8,061,502	 	 	 	4.7	%	 	 	360,640	 
	
                  
                    Southwest

                  

                	
                  
                    HF/HST 2-13
      M+F

                  

                	 	 	380,559	 	 	 	105.87	 	 	 	40,289,781	 	 	 	109.84	 	 	 	41,800,601	 	 	 	3.7	%	 	 	1,510,819	 
	
                  
                    Southwest

                  

                	
                  
                    HF/HST
      14-18 F

                  

                	 	 	51,497	 	 	 	176.47	 	 	 	9,087,676	 	 	 	183.12	 	 	 	9,430,131	 	 	 	3.8	%	 	 	342.455	 
	
                  
                    Southwest

                  

                	
                  
                    HF/HST
      14-18
      M

                  

                	 	 	44,200	 	 	 	126.64	 	 	 	5,597,488	 	 	 	130.86	 	 	 	5,784,012	 	 	 	3.3	%	 	 	186,524	 
	
                  
                    Southwest

                  

                	
                  
                    HF 19-44 F

                  

                	 	 	160,588	 	 	 	325.09	 	 	 	52,205,553	 	 	 	343.11	 	 	 	55,099,349	 	 	 	5.5	%	 	 	2,893,796	 
	
                  
                    Southwest

                  

                	
                  
                    HF
      19-44 M

                  

                	 	 	42,270	 	 	 	212.34	 	 	 	8,975,612	 	 	 	225.27	 	 	 	9,522,163	 	 	 	6.1	%	 	 	546,551	 
	
                  
                    Southwest

                  

                	
                  
                    HF
      45+ M+F

                  

                	 	 	17,095	 	 	 	518.94	 	 	 	8,871,020	 	 	 	541.93	 	 	 	9,264,022	 	 	 	4.4	%	 	 	393,003	 
	
                  
                    Southwest

                  

                	
                  
                    HST
      19-64
      F

                  

                	 	 	21,442	 	 	 	401.95	 	 	 	8,618,612	 	 	 	427.44	 	 	 	9,165,168	 	 	 	6.3	%	 	 	546,557	 
	
                  
                    Southwest

                  

                	
                  
                    Composite
      Non-Delivery

                  

                	 	 	834,997	 	 	 	218.81	 	 	 	182,708,500	 	 	 	229.24	 	 	 	191,411,242	 	 	 	4.8	%	 	 	8,702,743	 
	
                  
                    Southwest

                  

                	
                  
                    Delivery
      CFC

                  

                	 	 	3,675	 	 	 	4,011.88	 	 	 	14,743,659	 	 	 	4,242.15	 	 	 	15,589,901	 	 	 	5.7	%	 	 	846,242	 
	
                  
                    Southwest

                  

                	
                  
                    Composite
      with Delivery

                  

                	 	 	834,997	 	 	$	236.47	 	 	$	197,452,159	 	 	$	247.91	 	 	$	207,001,144	 	 	 	4.8	%	 	$	9,548,985	 
	
                  
                    West
      Central

                  

                	
                  
                    HF/HST <1 M+F

                  

                	 	 	44,127	 	 	$	572.54	 	 	$	25,264,473	 	 	$	602.37	 	 	$	26,580,781	 	 	 	5.2	%	 	$	1,316,308	 
	
                  
                    West
      Central

                  

                	
                  
                    HF/HST
      1 M+F

                  

                	 	 	32,928	 	 	 	147.65	 	 	 	4,861,819	 	 	 	155.40	 	 	 	5,117,011	 	 	 	5.2	%	 	 	255,192	 
	
                  
                    West
      Central

                  

                	
                  
                       HF/HST
      2-13 M+F

                  

                	 	 	264,267	 	 	 	99.86	 	 	 	26,389,703	 	 	 	104.16	 	 	 	27,526,051	 	 	 	4.3	%	 	 	1,136,348	 
	
                  
                    West.
      Central

                  

                	
                  
                    HF/HST
      14-18
      F

                  

                	 	 	38,572	 	 	 	166.47	 	 	 	6,420,998	 	 	 	173.67	 	 	 	6,698,712	 	 	 	4.3	%	 	 	277,715	 
	
                  
                    West
      Central

                  

                	
                  
                    HF/HST
      14-18
      M

                  

                	 	 	33,698	 	 	 	119.46	 	 	 	4,025,503	 	 	 	124.11	 	 	 	4,182,197	 	 	 	3.9	%	 	 	156,693	 
	
                  
                    West
      Central

                  

                	
                  
                    HF
      19-44 F

                  

                	 	 	117,439	 	 	 	306.66	 	 	 	36,013,844	 	 	 	325.39	 	 	 	38,213,476	 	 	 	6.1	%	 	 	2,199,632	 
	
                  
                    West
      Central

                  

                	
                  
                    HF
      19-44 M

                  

                	 	 	33,241	 	 	 	200.29	 	 	 	6,657,840	 	 	 	213.64	 	 	 	7,101,607	 	 	 	6.7	%	 	 	443,767	 
	
                  
                    West
      Central

                  

                	
                  
                    HF
      45+ M+F

                  

                	 	 	13,516	 	 	 	489.51	 	 	 	6,616,217	 	 	 	513.95	 	 	 	6,946,548	 	 	 	5.0	%	 	 	330,331	 
	
                  
                    West
      Central

                  

                	
                  
                    HST
      19-64 F

                  

                	 	 	13,711	 	 	 	379.15	 	 	 	5,198,526	 	 	 	405.37	 	 	 	5,558,028	 	 	 	6.9	%	 	 	359,502	 
	
                  
                    West
      Central

                  

                	
                  
                    Composite
      Non-Delivery

                  

                	 	 	591,498	 	 	 	205.32	 	 	 	121,448,922	 	 	 	216.27	 	 	 	127,924,412	 	 	 	5.3	%	 	 	6,475,490	 
	
                  
                    West
      Central

                  

                	
                  
                    Delivery
      CFC

                  

                	 	 	2,458	 	 	 	4,342,68	 	 	 	10,674,307	 	 	 	4,589.24	 	 	 	11,280,352
      	 	 	 	5.7	%	 	 	606,044	 
	
                  
                    West
      Central

                  

                	
                  
                    Composite
      with Delivery

                  

                	 	 	591,498	 	 	$	223.37	 	 	$	132,123,229	 	 	$	235.34
      	 	 	$	139,204,764
      	 	 	 	5.4	%	 	$	7,081,534	 
	
                  
                    Statewide

                  

                	
                  
                    HF/HST
      <l M+F

                  

                	 	 	445,688	 	 	$	568.11	 	 	$	253,199,638	 	 	$	596.61	 	 	$	265,901,895	 	 	 	5.0	%	 	$	12,702,257	 
	
                  
                    Statewide

                  

                	
                  
                    HF/HST
      1
      M+F

                  

                	 	 	341,402	 	 	 	146.35	 	 	 	49,965,476	 	 	 	153.76	 	 	 	52,492,435	 	 	 	5.1	%	 	 	2,526,959	 
	
                  
                    Statewide

                  

                	
                  
                    HF/HST
      2-13 M+F

                  

                	 	 	2,842,984	 	 	 	98.86	 	 	 	281,050,992	 	 	 	102.93	 	 	 	292,625,909	 	 	 	4.1	%	 	 	11,574,918	 
	
                  
                    Statewide

                  

                	
                  
                    HF/HST
      14-18 F

                  

                	 	 	410,043	 	 	 	164.57	 	 	 	67,480,948	 	 	 	171.39	 	 	 	70,277,281	 	 	 	4.1	%	 	 	2,796,333	 
	
                  
                    Statewide

                  

                	
                  
                    HF/HST
      14-18 M

                  

                	 	 	369,099	 	 	 	118.03	 	 	 	43,566,019	 	 	 	122.41	 	 	 	45,181,768	 	 	 	3.7	%	 	 	1,615,750	 
	
                  
                    Statewide

                  

                	
                  
                    HF
      19-44 F

                  

                	 	 	1,314,417	 	 	 	303.16	 	 	 	398,481,449	 	 	 	321.12	 	 	 	422,082,259	 	 	 	5.9	%	 	 	23,600,810	 
	
                  
                    Statewide

                  

                	
                  
                    HF
      19-44 M

                  

                	 	 	374,977	 	 	 	198.55	 	 	 	74,451,778	 	 	 	211.44	 	 	 	79,283,446	 	 	 	6.5	%	 	 	4,831,668	 
	
                  
                    Statewide

                  

                	
                  
                    HF
      45+ M+F

                  

                	 	 	161,762	 	 	 	482.65	 	 	 	78,074,142	 	 	 	505.86	 	 	 	81,829,027	 	 	 	4.8	%	 	 	3,754,885	 
	
                  
                    Statewide

                  

                	
                  
                    HST
      19-64
      F

                  

                	 	 	143,006	 	 	 	376.18	 	 	 	53,795,962	 	 	 	401.47	 	 	 	57,412,182	 	 	 	6.7	%	 	 	3,616,221	 
	
                  
                    Statewide

                  

                	
                  
                    Composite
      Non-

                  

                  
                    Delivery

                  

                	 	 	6,403,375	 	 	 	203.03	 	 	 	1,300,066,404	 	 	 	213.49	 	 	 	1,367.086,203	 	 	 	5.2	%	 	 	67,019,799	 
	
                  
                    Statewide

                  

                	
                  
                    Delivery
      CFC

                  

                	 	 	25,834	 	 	 	3,950.11	 	 	 	102,047,228	 	 	 	4,176.57	 	 	 	107,897,630	 	 	 	5.7	%	 	 	5,850,403	 
	
                  
                    Statewide

                  

                	
                  
                    Composite
      with Delivery

                  

                	 	 	6,403,375	 	 	$	218.96	 	 	$	1,402,113,632	 	 	$	230.34	 	 	$	1,474,983,833	 	 	 	5.2	%	 	$	72,870,202	 


        


        
          
             


          

          
            10

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      
        ENCLOSURE
2

      

      
         

      

      
        STATE
OF OHIO

      

      
        DEPARTMENT
OF JOB AND FAMILY SERVICES

      

      
        Covered
Families and Children

      

      
        Capitation
Rates July 1, 2008 to December
1, 2008

      

      
         

      

      
        Actuarial
Certification

      

      
         

      

      
        I,
Robert M.
Damler, am a
Principal and Consulting
Actuary with the firm of Milliman, Inc. I am a
Fellow of the Society of Actuaries and a Member of the American Academy of
Actuaries. 1 was retained by the State of Ohio, Department of Job and Family
Services to perform an actuarial review and certification regarding the
development of the capitation rates to be effective from July 1, 2008 to
December 31, 2008. The capitation rates were developed for the Covered Families
and Children managed care eligible populations. I have experience in the
examination of financial calculations for Medicaid programs and meet the
qualification standards for rendering this opinion.

      

      
         

      

      
        I
reviewed the historical claims
experience for reasonableness and consistency. I have developed certain
actuarial assumptions and actuarial methodologies regarding the projection of
healthcare expenditures into future periods. I have complied
with the elements of the rate setting checklist CM.S developed for its Regional
Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed care
plans.

      

      
         

      

      
        The
capitation rates provided with this certification are effective for a six month
rating period beginning July 1, 2008 through December 31, 2008. The
capitation rates associated with this certification were previously certified by
Milliman and approved by CMS for the period of Jan 1, 2008 through Dec 31, 2008.
This certification reflects modifications to the rates for policy and program
changes. At the end of the six month period, the capitation rates will be
updated for calendar year 2009. The update may be based on fee-for-service
experience, managed care utilization and trend experience, policy and procedure
changes, and other changes in the health care market. A separate certification
will be provided with the updated rates.

      

      
         

      

      
        The
capitation rates provided with this certification are considered actuarially
sound, defined as: the capitation rates have been developed  in
accordance with generally accepted  actuarial principles and
practices;
the capitation rates are appropriate for the populations to be covered, and the
services to be furnished under the contract; and, the capitation rates meet the
requirements of 42 CFR 438.6(c).

      

       

      
        
          
             


          

          
            11

            
              

            

          

          
            
              Appendix
E

              Covered
Families and Children (CFC) population  


            

          

        

      

       

      
        This
actuarial certification has been based on the actuarial methods, considerations,
and analyses promulgated from time to time through the Actuarial Standards of
Practice by the Actuarial Standards Board.

      

      
         

      

      
         

      

      
        /s/ Robert
Damler 

        Robert
M. Damler,
FSA

      

      
        Member,
American Academy of Actuaries

      

      
         

      

      
        June
5, 2008

      

      
        Date

      

      
         

         

        Milliman
makes
no representations or warranties regarding the contents of this letter to
third parties. 
Likewise,
third parties are instructed that they are to place no reliance upon
this letter prepared for ODJFS by Milliman that would result in the creation of
any duty or liability under any theory of law
by Milliman or its employees
to third parties. Other parties receiving this letter must rely upon their own
experts in drawing conclusions about the capitation rates,
assumptions,
and trends.

         

      

      
        
          
          

        

        
          12

          
            

          

        

        
          
            Appendix
F

            Covered
Families and Children (CFC) population   

          

        

      

       

      
        
          	
                  APPENDIX
      F

                	 
	
                  REGIONAL
      RATES

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  1. PREMIUM
      RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/08 THROUGH
      11/30/08 SHALL BE AS FOLLOWS:

                	 
	
                  An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

                	 
	
                  MCP:  WellCare
      of Ohio, Inc.

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  SERVICE

                	
                  REGIONAL

                	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HST

                	 	 	
                  Delivery

                	 
	
                  ENROLLMENT

                	
                  STATUS

                	 	
                  Age
      < 1

                	 	 	
                  Age
      1

                	 	 	
                  Age
      2-13

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      45

                	 	 	
                  Age
      19-64

                	 	 	
                  Payment

                	 
	
                  AREA

                	 
      	 	 	 	 	 	 	 	 	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  and
      over

                	 	 	
                  Female

                	 	 	 	 
	
                  Northeast

                	
                  Mandatory

                	 	$	564.33	 	 	$	145.58	 	 	$	97.58	 	 	$	116.25	 	 	$	162.70	 	 	$	200.14	 	 	$	304.84	 	 	$	481.47	 	 	$	379.76	 	 	$	4,343.69	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  List
      of Eligible Assistance Groups (AGs)

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Families:  - MA-C Categorically eligible due to TANF
      cash

                	 	 	 	 	 	 	 	 	 
	
                                                  - MA-T Children
      under 21

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                 
      - MA-Y Transitional Medicaid

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Start:        - MA-P Pregnant
      Women and Children

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  For
      the SFY 2009 contract period, MCPs will be put at-risk for a portion of
      the premiums received for members in regions they served as of January 1,
      2006, provided the MCP has participated in the program for more than
      twenty-four months. 

                   

                  MCPs
      will be put at-risk for a portion of the premiums received for members in
      regions they began serving after January 1, 2006, beginning with the
      MCP's twenty-fifth month of membership in each region. The at-risk amount
      will be determined separately for each region an MCP
    serves.

                	 	 	 	 	 


        

         

        
          
            
            

          

          
            1

            
              

            

          

          
            
              Appendix
F

              Covered
Families and Children (CFC) population   

            

          

        

         

        
          	
                  APPENDIX
      F

                	 
	
                  REGIONAL
      RATES

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  2. AT-RISK
      AMOUNTS FOR 07/01/08 THROUGH 11/30/08 SHALL BE AS
      FOLLOWS:

                	 
	
                  An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

                	 
	
                  MCP:  WellCare
      of Ohio, Inc.

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  SERVICE

                	
                  REGIONAL

                	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HST

                	 	 	
                  Delivery

                	 
	
                  ENROLLMENT

                	
                  STATUS

                	 	
                  Age
      < 1

                	 	 	
                  Age
      1

                	 	 	
                  Age
      2-13

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      45

                	 	 	
                  Age
      19-64

                	 	 	
                  Payment

                	 
	
                  AREA

                	 
      	 	 	 	 	 	 	 	 	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  and
      over

                	 	 	
                  Female

                	 	 	 	 
	
                  Northeast

                	
                  Mandatory

                	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  List
      of Eligible Assistance Groups (AGs)

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Families:  - MA-C Categorically eligible due to TANF
      cash

                	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                  - MA-T Children
      under 21

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                  - MA-Y Transitional
      Medicaid

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Start:        - MA-P Pregnant
      Women and Children

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 


        

        For the SFY 2009 contract period, MCPs
will be put at-risk for a portion of the premiums received for members in
regions they served as of January 1, 2006, provided the MCP has participated in
the program for more than twenty-four months.  

         

        MCPs will be put at-risk for a portion
of the premiums received for members in regions they began serving after January
1, 2006, beginning with the MCP's twenty-fifth month of
membership in each region. The at-risk amount will be determined separately for
each region an MCP serves.

         

        
          
            
            

          

          
            2

            
              

            

          

          
            
              Appendix
F

              Covered
Families and Children (CFC) population   

            

          

        

         

        
          	
                  APPENDIX
      F

                	 
	
                  REGIONAL
      RATES

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  3. PREMIUM
      RATES FOR 07/01/08 THROUGH 11/30/08 SHALL BE AS FOLLOWS:

                	 
	
                  An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

                	 
	
                  MCP:  WellCare
      of Ohio, Inc.

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  SERVICE

                	
                  REGIONAL

                	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HST

                	 	 	
                  Delivery

                	 
	
                  ENROLLMENT

                	
                  STATUS

                	 	
                  Age
      < 1

                	 	 	
                  Age
      1

                	 	 	
                  Age
      2-13

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      45

                	 	 	
                  Age
      19-64

                	 	 	
                  Payment

                	 
	
                  AREA

                	 
      	 	 	 	 	 	 	 	 	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  and
      over

                	 	 	
                  Female

                	 	 	 	 
	
                  Northeast

                	
                  Mandatory

                	 	$	564.33	 	 	$	145.58	 	 	$	97.58	 	 	$	116.25	 	 	$	162.70	 	 	$	200.14	 	 	$	304.84	 	 	$	481.47	 	 	$	379.76	 	 	$	4,343.69	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  List
      of Eligible Assistance Groups (AGs)

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Families:  - MA-C Categorically eligible due to TANF
      cash

                	 	 	 	 	 	 	 	 	 
	
                                                 
      - MA-T Children under 21

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                  - MA-Y Transitional
      Medicaid

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Start:  - MA-P Pregnant Women and Children

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  For
      the SFY 2009 contract period, MCPs will be put at-risk for a portion of
      the premiums received for members in regions they served as of January 1,
      2006, provided the

                	 	 	 	 	 
	
                  MCP
      has participated in the program for more than twenty-four months. 
      

                   

                  MCPs
      will be put at-risk for a portion of the premiums received for members in
      regions they began serving after January 1, 2006, beginning with
      the MCP's twenty-fifth month of membership in each region. The at-risk
      amount will be determined separately for each region an MCP
      serves.

                	 	 	 	 


        



        
          
             


          

          
            3

            
              

            

          

          
            
              Appendix
F

              Covered
Families and Children (CFC) population 


            

          

        

      

       

      
        	
                APPENDIX
      F

              	 
	
                REGIONAL
      RATES

              	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                1. PREMIUM
      RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/08 THROUGH
      12/31/08 SHALL BE AS FOLLOWS:

              	 
	
                An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

              	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
      of Ohio, Inc.

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	 	
                HF/HST

              	 	 	
                HF/HST

              	 	 	
                HF/HST

              	 	 	
                HF/HST

              	 	 	
                HF/HST

              	 	 	
                HF

              	 	 	
                HF

              	 	 	
                HF

              	 	 	
                HST

              	 	 	
                Delivery

              	 
	
                ENROLLMENT

              	
                STATUS

              	 	
                Age
      < 1

              	 	 	
                Age
      1

              	 	 	
                Age
      2-13

              	 	 	
                Age
      14-18

              	 	 	
                Age
      14-18

              	 	 	
                Age
      19-44

              	 	 	
                Age
      19-44

              	 	 	
                Age
      45

              	 	 	
                Age
      19-64

              	 	 	
                Payment

              	 
	
                AREA

              	 
      	 	 	 	 	 	 	 	 	 	 	
                Male

              	 	 	
                Female

              	 	 	
                Male

              	 	 	
                Female

              	 	 	
                and
      over

              	 	 	
                Female

              	 	 	 	 
	
                Northeast

              	
                Mandatory

              	 	$	559.00	 	 	$	144.20	 	 	$	96.66	 	 	$	115.15	 	 	$	161.16	 	 	$	198.25	 	 	$	301.96	 	 	$	476.92	 	 	$	376.17	 	 	$	4,302.64	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
      of Eligible Assistance Groups (AGs)

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Healthy
      Families:   - MA-C Categorically eligible due to TANF
      cash

              	 	 	 	 	 
	
                                                
      - MA-T Children under 21

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                
      - MA-Y Transitional Medicaid

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Healthy
      Start:        
      - MA-P Pregnant Women and Children

              	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                For
      the SFY 2009 contract period, MCPs will be put at-risk for a portion of
      the premiums received for members in regions they served as of January 1,
      2006, provided the MCP has participated in the program for more than
      twenty-four months. 

                 

                MCPs
      will be put at-risk for a portion of the premiums received for members in
      regions they began serving after January 1, 2006, beginning with the
      MCP's twenty-fifth month of membership in each region. The at-risk amount
      will be determined separately for each region an MCP
      serves. WellCare's regions at risk: Northeast

              	 	 	 	 	 	 	 	 	 


      

      


      
        
          
             


          

          
            4

            
              

            

          

          
            
              Appendix
F

              Covered
Families and Children (CFC) population 


            

          

        

      

       

      
        
          	
                  APPENDIX
      F

                	 
	
                  REGIONAL
      RATES

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  2. AT-RISK
      AMOUNTS FOR 12/01/08 THROUGH 12/31/08 SHALL BE AS
      FOLLOWS:

                	 
	
                  An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  MCP:  WellCare
      of Ohio, Inc.

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  SERVICE

                	
                  REGIONAL

                	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HST

                	 	 	
                  Delivery

                	 
	
                  ENROLLMENT

                	
                  STATUS

                	 	
                  Age
      < 1

                	 	 	
                  Age
      1

                	 	 	
                  Age
      2-13

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      45

                	 	 	
                  Age
      19-64

                	 	 	
                  Payment

                	 
	
                  AREA

                	 
      	 	 	 	 	 	 	 	 	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  and
      over

                	 	 	
                  Female

                	 	 	 	 
	
                  Northeast

                	
                  Mandatory

                	 	$	5.33	 	 	$	1.38	 	 	$	0.92	 	 	$	1.10	 	 	$	1.54	 	 	$	1.89	 	 	$	2.88	 	 	$	4.55	 	 	$	3.59	 	 	$	41.05	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  List
      of Eligible Assistance Groups (AGs)

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Families:   - MA-C Categorically eligible due to TANF
      cash

                	 	 	 	 	 
	
                                                   - MA-T Children
      under 21

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                   - MA-Y Transitional
      Medicaid

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Start:        
      - MA-P Pregnant Women and Children

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  For
      the SFY 2009 contract period, MCPs will be put at-risk for a portion of
      the premiums received for members in regions they served as of January
      1, 2006, provided the MCP has participated in the program for more than
      twenty-four months.

                	 	 	 	 	 
	
                   

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  MCPs
      will be put at-risk for a portion of the premiums received for members in
      regions they began serving after January 1, 2006, beginning with
      the MCP's twenty-fifth month of membership in each region. The at-risk
      amount will be determined separately for each region an MCP serves. WellCare's
      regions at risk: Northeast.

                	 	 	 	 	 


        

      

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
F

            Covered
Families and Children (CFC) population

          

        

      

      


      
        
          	
                  APPENDIX
      F

                	 
	
                  REGIONAL
      RATES

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  3. PREMIUM
      RATES FOR 12/01/08 THROUGH 12/31/08 SHALL BE AS FOLLOWS:

                	 
	
                  An
      at-risk amount of 1% is applied to the MCP rates. The status of the
      at-risk amount is determined in accordance with Appendix O, performance
      incentives.

                	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  MCP:  WellCare
      of Ohio, Inc.

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  SERVICE

                	
                  REGIONAL

                	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF/HST

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HF

                	 	 	
                  HST

                	 	 	
                  Delivery

                	 
	
                  ENROLLMENT

                	
                  STATUS

                	 	
                  Age
      < 1

                	 	 	
                  Age
      1

                	 	 	
                  Age
      2-13

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      14-18

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      19-44

                	 	 	
                  Age
      45

                	 	 	
                  Age
      19-64

                	 	 	
                  Payment

                	 
	
                  AREA

                	 
      	 	 	 	 	 	 	 	 	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  Male

                	 	 	
                  Female

                	 	 	
                  and
      over

                	 	 	
                  Female

                	 	 	 	 
	
                  Northeast

                	
                  Mandatory

                	 	$	564.33	 	 	$	145.58	 	 	$	97.58	 	 	$	116.25	 	 	$	162.70	 	 	$	200.14	 	 	$	304.84	 	 	$	481.47	 	 	$	379.76	 	 	$	4,343.69	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  List
      of Eligible Assistance Groups (AGs)

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Families:   - MA-C Categorically eligible due to TANF
      cash

                	 	 	 	 	 
	
                                                   - MA-T Children
      under 21

                	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                                                  
      - MA-Y Transitional Medicaid

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  Healthy
      Start:        
      - MA-P Pregnant Women and Children

                	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
      	 
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  For
      the SFY 2009 contract period, MCPs will be put at-risk for a portion of
      the premiums received for members in regions they served as of January 1,
      2006, provided the MCP has participated in the program for more than
      twenty-four months.

                	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                  MCPs
      will be put at-risk for a portion of the premiums received for members in
      regions they began serving after January 1, 2006, beginning with the
      MCP's twenty-fifth month of membership in each region. The at-risk amount
      will be determined separately for each region an MCP
      serves. WellCare's regions at risk: Northeast.

                	 	 	 	 	 	 	 	 	 


        


        
          
             


          

          
            6

            
              

            

          

          
            
              Appendix
G

              Covered
Families and Children (CFC)
population 

            

          

        

APPENDIX
G

      


      COVERAGE
AND SERVICES

      CFC
ELIGIBLE POPULATION

      


      1.            
Basic Benefit
Package

      


      Pursuant
to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2 of this
appendix), MCPs must ensure that members have access to medically-necessary
services covered by the Ohio Medicaid fee-for-service (FFS)
program.  For information on Medicaid-covered services, MCPs must
refer to the ODJFS website. The following is a general list of the benefits
covered by the Ohio Medicaid fee-for-service program:

      


      
        	
                 
      

              	
                ·

              	
                Inpatient
      hospital services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Outpatient
      hospital services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Rural
      health clinics (RHCs) and Federally qualified health centers
      (FQHCs)

              


      

      


      
        	
                 
      

              	
                ·

              	
                Physician
      services whether furnished in the physician’s office, the covered person’s
      home, a hospital, or elsewhere

              


      

      


      
        	
                 
      

              	
                ·

              	
                Laboratory
      and x-ray services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Screening,
      diagnosis, and treatment services to children under the age of twenty-one
      (21) under the HealthChek (EPSDT)
program

              


      

      


      
        	
                 
      

              	
                ·

              	
                Family
      planning services and supplies

              


      

      


      
        	
                 
      

              	
                ·

              	
                Home
      health and private duty nursing
services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Podiatry

              


      

      


      
        	
                 
      

              	
                ·

              	
                Chiropractic
      services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Physical
      therapy, occupational therapy, developmental therapy and speech
      therapy

              


      

      


      
        	
                 
      

              	
                ·

              	
                Nurse-midwife,
      certified family nurse practitioner, and certified pediatric nurse
      practitioner services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Prescription
      drugs

              


      

      


      
        	
                 
      

              	
                ·

              	
                Ambulance
      and ambulette services

              


      

       

      
        	
                 
      

              	
                ·

              	
                Dental
      services

              


      

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                 
      

              	
                ·

              	
                Durable
      medical equipment and medical
supplies

              


      

      


      
        	
                 
      

              	
                ·

              	
                Vision
      care services, including eyeglasses

              


      

      


      
        	
                 
      

              	
                ·

              	
                Nursing
      facility stays as specified in OAC rule
  5101:3-26-03

              


      

      


      
        	
                 
      

              	
                ·

              	
                Hospice
      care

              


      

      


      
        	
                 
      

              	
                ·

              	
                Behavioral
      health services (see section G.2.b.iii of this
  appendix)

              


      

       

      2.        
    Exclusions, Limitations and
Clarifications

      


      a.           Exclusions

                                                   


                                                   
MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid)
non-covered services. For information regarding Medicaid
noncovered     

                                                   
services, MCPs must refer to the ODJFS website. The following is a general
list of the services not covered by the Ohio Medicaid fee-for-service
program:

      


      
        	
                 
      

              	
                ·

              	
                Services
      or supplies that are not medically
necessary

              


      

      


      
        	
                 
      

              	
                ·

              	
                Experimental
      services and procedures, including drugs and equipment, not covered by
      Medicaid

              


      

      


      
        	
                 
      

              	
                ·

              	
                Organ
      transplants that are not covered by
Medicaid

              


      

      


      
        	
                 
      

              	
                ·

              	
                Abortions,
      except in the case of a reported rape, incest, or when medically necessary
      to save the life of the mother

              


      

      


      
        	
                 
      

              	
                ·

              	
                Infertility
      services for males or females

              


      

      


      
        	
                 
      

              	
                ·

              	
                Voluntary
      sterilization if under 21 years of age or legally incapable of consenting
      to the procedure

              


      

      


      
        	
                 
      

              	
                ·

              	
                Reversal
      of voluntary sterilization
procedures

              


      

      


      
        	
                 
      

              	
                ·

              	
                Plastic
      or cosmetic surgery that is not medically
  necessary*

              


      

      


      
        	
                 
      

              	
                ·

              	
                Immunizations
      for travel outside of the United
States

              


      

      


      
        	
                 
      

              	
                ·

              	
                Services
      for the treatment of obesity unless medically
  necessary*

              


      

       

      ·      Custodial
or supportive care not covered by Medicaid

      


      
        	
                 
      

              	
                ·

              	
                Sex
      change surgery and related services

              


      

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                 
      

              	
                ·

              	
                Sexual
      or marriage counseling

              


      

      


      
        	
                 
      

              	
                ·

              	
                Acupuncture
      and biofeedback services

              


      

      


      
        	
                 
      

              	
                ·

              	
                Services
      to find cause of death (autopsy)

              


      

      


      
        	
                 
      

              	
                ·

              	
                Comfort
      items in the hospital (e.g., TV or
phone)

              


      

      


      
        	
                 
      

              	
                ·

              	
                Paternity
      testing

              


      

       

       
MCPs are also not required to pay for non-emergency services or supplies
received without members following the directions in their MCP member


       
handbook, unless otherwise directed by ODJFS.

      


      
        	
                 
      

              	
                *These services could be
      deemed medically necessary if medical complications/conditions in addition
      to the obesity or physical imperfection are
  present.

              


      

      


      b.           Limitations &
Clarifications

      
 
i.               
Member
Cost-Sharing

      


      As
specified in OAC rules 5101:3-26-05(D) and  5101:3-26-12, MCPs are
permitted to impose the applicable member co-payment amount(s) for dental
services, vision services, non-emergency emergency department services, or
prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
intend to impose a co-payment.  ODJFS must approve the notice to be
sent to the MCP’s members and the timing of when the co-payments will begin to
be imposed.  If ODJFS determines that an MCP’s decision to impose a
particular co-payment on their members would constitute a significant change for
those members, ODJFS may require the effective date of the co-payment to
coincide with the “Open Enrollment” month.

      


      Notwithstanding
the preceding paragraph, MCPs must provide an ODJFS-approved notice to all their
members 90 days in advance of the date that the MCP will impose the co-payment.
With the exception of member co-payments the MCP has elected to implement in
accordance with OAC rules 5101:3-26-05(D) and  5101:3-26-12, the MCP’s
payment constitutes payment in full for any covered services and their
subcontractors must not charge members or ODJFS any additional co-payment, cost
sharing, down-payment, or similar charge, refundable or otherwise.

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

        ii.              
Abortion and
Sterilization

      


      The use
of federal funds to pay for abortion and sterilization services is prohibited
unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01 and
5101:3-21-01 are met.  MCPs must verify that all of the information on
the required forms (JFS 03197, 03198, and 03199) is provided and that the
service meets the required criteria before any such claim is paid.

      


      Additionally,
payment must not be made for associated services such as anesthesia, laboratory
tests, or hospital services if the abortion or sterilization itself does not
qualify for payment.  MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems edits to ensure that claims are only paid once the MCP has determined if
the applicable forms are completed and the required criteria are met, as
confirmed by the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.

       


       
iii.        
     Behavioral Health
Services

      


      Coordination of
Services:  MCPs must have a process to coordinate benefits of
and referrals to the publicly funded community behavioral health
system.  MCPs must ensure that members have access to all
medically-necessary behavioral health services covered by the Ohio Medicaid FFS
program and are responsible for coordinating those services with other medical
and support services.  MCPs must notify members via the member
handbook and provider directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through ODMH community mental health centers (CMHCs) as well as substance abuse
services offered through Ohio Department of Alcohol and Drug Addiction Services
(ODADAS)-certified Medicaid providers. Pursuant to ORC Section 5111.16, alcohol,
drug addiction and mental health services covered by Medicaid are not to be paid
by the managed care program when the nonfederal share of the cost of those
services is provided by a board of alcohol, drug addiction, and mental health
services or a state agency other than ODJFS.  MCPs are also not
responsible for providing mental health services to persons
between 22 and 64 years of age while residing in an institution for mental
disease (IMD) as defined in Section 1905(i) of the Social Security
Act.

      


      MCPs must
provide Medicaid-covered behavioral health services for members who are unable
to timely access services or are unwilling to access services through community
providers.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

       Mental Health
Services: There are a number of Medicaid-covered mental health
(MH) services available through ODMH CMHCs.

      


      Where an
MCP is responsible for providing MH services for their members, the MCP is
responsible for ensuring access to counseling and psychotherapy,
physician/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization screening,
diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and Medicaid-covered
prescription drugs and laboratory services.  MCPs are not required to
cover partial hospitalization, or inpatient psychiatric care in a private or
public free-standing psychiatric hospital. However, MCPs are required to cover
the payment of physician services in a private or public free-standing
psychiatric hospital when such services are billed independent of the
hospital.  The payment of physician services in an IMD is also covered
by the MCPs, as long as the member is 21 years of age and under or 65 years of
age and older.     

       

      
        Substance Abuse
Services:  There are a number of Medicaid-covered substance
abuse services available through ODADAS-certified Medicaid
providers.

        


        Where an
MCP is responsible for providing substance abuse services for their members, the
MCP is responsible for ensuring access to alcohol and other drug (AOD)
urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services, general hospital outpatient AOD treatment services,
crisis intervention, inpatient detoxification services in a general hospital,
and Medicaid-covered prescription drugs and laboratory services. MCPs are not
required to cover outpatient detoxification, intensive outpatient programs
(IOP)(substance abuse) or methadone maintenance.

      

       

      Financial Responsibility for
Behavioral Health Services:  MCPs are responsible for the
following:

      
        	
                 
      

              	
                ·

              	
                payment
      of Medicaid-covered prescription drugs prescribed by an ODMH CMHC or
      ODADAS-certified provider when obtained through an MCP’s panel
      pharmacy;

              


      

      
        	
                 
      

              	
                ·

              	
                payment
      of Medicaid-covered services provided by an MCP’s panel laboratory when
      referred by an ODMH CMHC or ODADAS-certified
  provider;

              


      

      
        	
                 
      

              	
                ·

              	
                payment
      of all other Medicaid-covered behavioral health services obtained through
      providers other than those who are ODMH CMHCs or ODADAS-certified
      providers when arranged/authorized by the
MCP.

              


      

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Limitations:

      
        	
                 
      

              	
                ·

              	
                Pursuant
      to ORC Section 5111.16, alcohol, drug addiction and mental health services
      covered by Medicaid are not to be paid by the managed care program when
      the nonfederal share of the cost of those services is provided by a board
      of alcohol, drug addiction, and mental health services or a state agency
      other than ODJFS.  As part of this
  limitation:

              


      

      


      
        	
                 
      

              	
                ·

              	
                MCPs
      are not responsible for paying for behavioral health services provided
      through ODMH CMHCs and ODADAS-certified Medicaid
  providers;

              


      

      
        	
                 
      

              	
                ·

              	
                MCPs
      are not responsible for payment of partial hospitalization (mental
      health), inpatient psychiatric care in a private or public free-standing
      inpatient psychiatric hospital, outpatient detoxification, intensive
      outpatient programs (IOP) (substance abuse) or methadone
      maintenance.

              


      

      
        	
                 
      

              	
                ·

              	
                However,
      MCPs are required to cover the payment of physician services in a private
      or public free-standing psychiatric hospital when such services are billed
      independent of the hospital.

              


      

       

      
        	
                 
      

              	
                iv.

              	
                Pharmacy
      Benefit:  In providing the Medicaid pharmacy benefit to
      their members, MCPs must cover the same drugs covered by the Ohio
      Medicaid fee-for-service program, in accordance with OAC rule
      5101:3-26-03(A) and (B).

              


      

      


      
        	
                 
      

              	
                Pursuant
      to ORC Section 5111.172, MCPs may, subject to ODJFS approval, implement
      strategies for the management of drug utilization. (see appendix
      G.3.a).

              


      

       

      
        	 	
                v.
      

              	Organ
      Transplants: MCPs must ensure coverage for organ
      transplants and related services in accordance with OAC 5101-3-2-07.1
      (B)(4)& (5).  Coverage
      for
      all organ transplant services, except kidney transplants, is contingent
      upon review and recommendation by the “Ohio Solid Organ
      Transplant
      Consortium”
      based on criteria established by Ohio organ transplant surgeons and
      authorization from the ODJFS prior authorization
      unit.  Reimbursement
      for bone marrow transplant and hematapoietic stem cell transplant
      services, as defined in OAC 3701:84-01, is contingent
      upon review and
      recommendation by the “Ohio Hematapoietic Stem Cell Transplant Consortium”
      again based on criteria established by Ohio experts
      in the
      field of bone
      marrow transplant.  While MCPs may require prior
      authorization for these transplant services, the approval criteria would
      be limited to
      confirming the
      consumer is being considered and/or has been recommended for a
      transplant by either consortium and authorized by ODJFS.  Additionally,
      in accordance
      with OAC 5101:3-2-03 (A)(4) all services related to organ donations are
      covered for the donor recipient when the
      consumer is Medicaid eligible.


      

              

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                3.

              	
                Care
      Coordination

              


      

      


              a.           Utilization Management
Programs

       

                                                   
General Provisions
- Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement
a utilization management (UM) program to maximize
the        

                                                   
effectiveness of the care provided to members and may develop other UM
programs, subject to prior approval by ODJFS.  For the purposes of
this  

                                                   
requirement, the specific UM programs which
require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled
substances and member 

                                                   
management program, and any other program designed by the MCP with the purpose
of redirecting or restricting access to a particular service or service


                                                   
location.

      


      
        	
                 
      

              	
                i.

              	
                Pharmacy
      Programs - Pursuant to ORC Sec. 5111.172, MCPs may, subject to ODJFS
      prior-approval, implement strategies for the management of drug
      utilization.  Pharmacy utilization management strategies may
      include
      developing preferred drug lists, requiring prior authorization for certain
      drugs, placing limitations on the type of provider and locations where
      certain medications may be administered, and developing and implementing a
      specialized pharmacy program to address the utilization of controlled
      substances, as defined in section 3719.01 of the Ohio Revised
      Code.  MCPs may also implement a retrospective
      drug utilization review program designed to promote the appropriate
      clinical prescribing of covered drugs.

              	
                 

              


      

      


      Drug
Prior Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior authorization.  MCPs
must establish their prior authorization system so that it does not
unnecessarily impede member access to medically-necessary Medicaid-covered
services.  MCPs must make their approved list of drugs covered only
with prior authorization available to members and providers, as outlined in
paragraphs 37(b) and (c) of Appendix C.

      


      While
MCPs may, with ODJFS approval,    require prior
authorization for the coverage of 2nd
generation antipsychotic drugs, MCPs must allow any member to continue receiving
a specific 2nd
generation antipsychotic drug if the member is stabilized on that particular
medication.  The MCP must continue to cover that specific
antipsychotic for the stabilized member for as long as that medication continues
to be effective for the member.  MCPs must also collaborate with ODJFS
in the retrospective review of 2nd generation antipsychotic utilization.


       

      
        
          
          

        

        
          7

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      MCPs must
comply with the provisions of 1927(d)(5) of the Social Security Act, 42 USC
1396r-8(k)(3), and
OAC rule 5101:3-26-03.1 regarding the timeframes for prior authorization of
covered outpatient drugs.

      


      Controlled
Substances and Member Management Programs: MCPs may also, with ODJFS prior
approval, develop and implement Controlled Substances and Member
Management  (CSMM) programs designed to address use of controlled
substances. Utilization management strategies may include prior authorization as
a condition of obtaining a controlled substance, as defined in section 3719.01
of the Ohio Revised Code.  CSMM strategies may also include processes
for requiring MCP members at high risk for fraud or abuse involving controlled
substances to have their controlled substances prescribed by a
designated provider/providers and filled by a pharmacy, medical provider, or
health care facility designated by the program.

       

      
        	
                 
      

              	
                ii.

              	
                Emergency Department
      Diversion (EDD) – MCPs must
      provide access to services in a way that assures access to
      primary,  specialist and urgent care in the most appropriate
      settings and that minimizes frequent, preventable utilization of emergency
      department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires
      MCPs to implement the ODJFS-required emergency department diversion (EDD)
      program for frequent utilizers.

              


      

       

      Each MCP
must establish an ED diversion  (EDD) program with the goal of
minimizing frequent ED utilization. The MCP’s EDD program must include the
monitoring of ED utilization, identification of frequent ED utilizers, and
targeted approaches designed to reduce avoidable ED utilization. MCP EDD
programs must, at a minimum, address those ED visits which could have been
prevented through improved education, access, quality or care management
approaches.

      


      Although
there is often an assumption that frequent ED visits are solely the result of a
preference on the part of the member and education is therefore the standard
remedy, it is also important to ensure that a member’s frequent ED utilization
is not due to problems such as their PCP’s lack of accessibility or failure to
make appropriate specialist referrals.  The MCP’s EDD program must
therefore also include the identification of providers who serve as PCPs for a
substantial number of frequent ED utilizers and the implementation of corrective
action with these providers as so indicated.

       

      
        	
                 
      

              	 	
                This
      requirement does not replace the MCP’s responsibility to inform and
      educate all members regarding the appropriate use of the
    ED.

              


      

       

      
        
          
          

        

        
          8

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

                                      
b.           Care Management
Programs

      


      In
accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide care
management services which coordinate and monitor the care of members who require
high-cost and/or extensive services.  The MCP’s care management
program must also include a Children with Special Health Care Needs component as
specified below.

      


      
        	
                 
      

              	
                i.

              	
                Each
      MCP must inform all members and contracting providers of the MCP’s care
      management services.

              


      

      


      
        	
                 
      

              	
                ii.

              	
                Children
      with Special Health Care Needs
(CSHCN):

              


      

      


      CSHCN are
a particularly vulnerable population which often have chronic and complex
medical health care conditions.  In order to ensure
compliance with the provisions of 42 CFR 438.208, each MCP must establish a
CSHCN component as part of the MCP’s care management program.  The MCP
must establish a process for the timely identification, completion of a
comprehensive health assessment, and providing appropriate care management
services for any CSHCN.

      


                                                            
CSHCN are defined as children age 17 and under who are pregnant, and members
under 21 years of age with one or more of the following:

      -Asthma

      -HIV/AIDS

      -A
chronic physical, emotional or mental condition for which they are receiving
treatment or counseling

      -Supplemental
security income (SSI) for a health-related condition

      -A
current letter of approval from the Bureau of Children with Medical Handicaps
(BCMH), Ohio Department of Health

       

      
        
          
          

        

        
          9

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                 
      

              	
                iii.

              	
                Care Management
      Program

              


      

      


      
        	
                 
      

              	
                1.

              	
                The
      MCP must have a process to inform members and their PCPs in writing that
      they have been identified as meeting the criteria for care management,
      including their enrollment into a  care  management
      program.

              


      

      


      
        	
                 
      

              	
                2.

              	
                The
      MCP must assure and coordinate the placement of the member into care
      management – including identification of the member’s need for care
      management services, completion of the comprehensive health assessment,
      and timely development of a care treatment plan.  This process
      must occur within the following timeframes
for:

              


      

      


      a) newly enrolled members, 90 days
from the effective date    of enrollment; and

      


      b) existing members, 90 days from
identifying their need     for care
management.

       

      
        	
                 
      

              	
                3.

              	
                The
      MCP’s care management program must include, at a minimum, the following
      components:

              


      

      


      
        	 	
                a.  

              	
                Identification

              


      

      The MCP
must have a variety of mechanisms in place to identify members potentially
eligible for care management.  These mechanisms must include an
administrative data review (e.g., diagnosis, cost threshold, and/or service
utilization) and may include provider/self referrals, telephone interviews,
information as reported by MCEC during membership selection, or home
visits.

      


      
        	
                 
      

              	
                b.

              	
                Assessment

              


      

      
        	
                 
      

              	
                The
      MCP must arrange for or conduct an initial comprehensive health assessment
      to confirm the results of a positive identification, and determine the
      need for care management services.

              


      

      


      The
comprehensive health assessment must evaluate the member’s medical condition(s),
including physical, behavioral, social, and psychological
needs.    The comprehensive health assessment must also
evaluate if the member has co-morbidities, or multiple complex health care
conditions.  The goals of the assessment are to identify the member’s
existing and/or potential health care needs and assess the member’s need for
care management services.

       

      
        
          
          

        

        
          10

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      The
assessment must be completed by a physician, physician assistant, RN, LPN,
licensed social worker, or a graduate of a two- or four-year allied health
program.  If the assessment is completed by a physician assistant,
LPN, licensed social worker, or a graduate of a two- or four-year allied health
program, there should be oversight and monitoring by either a registered nurse
or physician.

      


      The MCP
must develop a strategy to assign members to risk stratification levels, based
on the member’s comprehensive health  assessment.

       

      
        	
              	
                c.

              	
                Care Treatment
      Plan

              


      

       

      The care treatment plan is defined by ODJFS as the one developed by
the MCP for the member.  The development of the care treatment plan
must be based on the comprehensive health assessment, and reflect the member’s
medical condition(s), including physical, behavioral, social, and psychological
needs, as well as co-morbidities. The care treatment plan must also include
specific provisions for periodic reviews of the member's health care needs.
Periodic reviews may include administrative data reviews or screening questions
to alert appropriately qualified MCP staff to update the comprehensive health
assessment and  the care treatment plan.  At a minimum,
there must be verbal/written contact with the member once every six (6)
months.  The MCP must ensure there is a provision for two-way
communication or feedback with the MCP.


       

      The
member and the member's PCP must be actively involved in the development of, and
revisions to, the care treatment plan.  The designated PCP is the
provider, or specialist, who will manage and coordinate the overall care for the
member.  Ongoing communication regarding the status of the care
treatment plan may be accomplished between the MCP and the PCP's designee (i.e.,
qualified health professional).  Revisions to the clinical portion of
the care treatment plan should be completed in consultation with the
PCP.

      


      The elements of a care treatment plan
include:

      


      Goals and
actions that address health care conditions identified in the comprehensive
health assessment; 

      Member level interventions (i.e., referrals and making
appointments) that assist members in obtaining services, providers and programs
related to the health care conditions identified in the comprehensive health
assessment; 

       

      
        
          
          

        

        
          11

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Continuous
review, revision and contact follow-up, as needed,to insure the care treatment
plan is adequately monitored including the following:

      


      
        	
                 
      

              	
                ·

              	
                Documentation
      that services are provided in accordance with the care treatment
      plan;

              


      

      
        	
                 
      

              	
                ·

              	
                Re-evaluation
      to determine if the care treatment plan is adequate to meet the member's
      health care needs;

              


      

      
        	
                 
      

              	
                ·

              	
                Identification
      of gaps between recommended care and actual care
  provided;

              


      

      
        	
                 
      

              	
                ·

              	
                A
      change in needs or status from the re-evaluation that requires revisions
      to the care treatment plan; and

              


      

      
        	
                 
      

              	
                ·

              	
                Re-evaluation
      of a member's risk level with adjustment to the level of care management
      services provided.

              


      

       

      4.    
Coordination of Care
and Communication

      


      The MCP
must provide care management services for:

      


      
        	
                 
      

              	
                ·

              	
                all
      CSHCN, including the ODJFS mandated conditions as specified in Appendix M,
      Care Management Program Performance
Measures;

              


      

      


      
        	
                 
      

              	
                ·

              	
                all
      members enrolled in an MCP’s CSMM program as specified in Section
      G(3)(a)(i); and

              


      

       

      ·      adults
whose health conditions warrant care management services.

      


      Care
management services should not be limited only to members with the mandated
conditions.

      


      There
should be an accountable point of contact (i.e., case manager) who can help
obtain medically necessary care, assist with health-related services and
coordinate care needs. The MCP must arrange or provide for professional
care management services that are performed collaboratively by a team of
professionals appropriate for the member’s condition and health care
needs.  At a minimum, the MCP’s care manager must attempt to
coordinate with the member’s care manager from other health
systems.  The MCP must have a process to facilitate, maintain, and
coordinate communication between service providers, the member, and the member’s
family.  The MCP must have a provision to disseminate information to
the member/caregiver concerning the health condition, types of services that may
be available, and how to access the services.

       

      
        
          
          

        

        
          12

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      The MCP
must implement mechanisms to notify all Members with Special Health Care Needs
of their right to directly access a specialist.  Such access may be
assured through, for example, a standing referral or an approved number of
visits, and documented in the care treatment plan.

       

                                          iv.           Care
Management Strategies

      


      The MCP
must follow best-practice and/or evidence based clinical guidelines when
developing a member’s care treatment plan and coordinating the care management
needs. The MCP must develop and implement mechanisms to educate and equip
providers and care managers with evidence-based clinical guidelines or best
practice approaches to assist in providing a high level of quality of care to
members.

       

      v.           
Care Management Program Staffing

      


      The MCP
must identify the staff that will be involved in the operations of the care
management program, including but not limited to:  care manager
supervisors, care manager, and administrative support staff.  The MCP
must identify the role and functions of each care management staff member as
well as the educational requirements, clinical licensure standards, certification
and relevant experience with care management standards and/or
activities.  The MCP must provide care manager staff/member ratios
based on the member risk stratification and different levels of care being
provided to members.

      


                                                      vi.          
Care Management Data Submission

       

      The MCP
must submit a monthly electronic report to the Care Management System (CAMS) for
all members who are provided care management services by the MCP as outlined in
the ODJFS Case Management File
and Submission Specifications.In order for a member to be submitted as
care managed in CAMS, the MCP must (1) complete the identification process, a
comprehensive  health assessment  and development of a care
treatment plan for the member; and (2) document the member’s written or verbal
confirmation of his/her care management status in the care management
record.  ODJFS, or its designated entity, the external quality review
vendor, will validate on an annual basis the accuracy of the information
contained in CAMS with the member’s care management record.

       

      
        
          
          

        

        
          13

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      The CAMS
files are due the 15th
calendar day of each month.

      


      
        	
                 
      

              	
                The
      MCP must also have an ODJFS-approved care management program which
      includes the items in Section 3.b..  Each MCP should implement
      an evaluation process to review, revise and/or update the care management
      program.  The MCP must annually submit its care management
      program for review and approval by ODJFS. Any subsequent changes to an
      approved care management program description must be submitted to ODJFS in
      writing for review and approval prior to
  implementation.

              


      

       

      c.       
    Care Coordination with
ODJFS-Designated Providers

      


      Per OAC
rule 5101:3-26-03.1(A)(4), MCPs are required to share specific information with
certain ODJFS-designated non-contracting providers in order to ensure that these
providers have been supplied with specific information needed to coordinate
care for the MCP’s  members.  Once an MCP has obtained a
provider agreement, but within the first month of operation, the MCP must
provide to the ODJFS-designated providers (i.e., ODMH Community Mental Health
Centers, ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if
applicable], and hospitals) a quick reference information packet which includes
the following:

      


      
        	
                 
      

              	
                i.

              	
                A
      brief cover letter explaining the purpose of the mailing;
    and

              


      

      


      
        	
                 
      

              	
                ii.

              	
                A
      brief summary document that includes the following
      information:

              


      

      


      
        	
                 
      

              	
                ·

              	
                Claims
      submission information including the MCP’s Medicaid provider number for
      each region;

              


      

      


      
        	
                 
      

              	
                ·

              	
                The
      MCP’s prior authorization and referral procedures or the MCP’s website
      which includes this information;

              


      

       

      
        
          
          

        

        
          14

          
            

          

        

        
          
            Appendix
G

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                 
      

              	
                ·

              	
                A
      picture of the MCP’s member identification card (front and
      back);

              


      

       

      
        	
                 
      

              	
                ·

              	
                Contact
      numbers and website location for obtaining information for eligibility
      verification, claims processing, referrals/prior authorization, and
      information regarding the MCP’s behavioral health
      administrator;

              


      

      


      
        	
                 
      

              	
                ·

              	
                A
      listing of the MCP’s major pharmacy chains and the contact number for the
      MCP’s pharmacy benefit administrator
(PBM);

              


      

      


      
        	
                 
      

              	
                ·

              	
                A
      listing of the MCP’s laboratories and radiology providers;
    and

              


      

      


      
        	
                 
      

              	
                ·

              	
                A
      listing of the MCP’s contracting behavioral health providers and how to
      access services through them (this information is only to be provided to
      non-contracting community mental health and substance abuse
      providers).

              


      

      


      d.          
 Care
coordination with Non-Contracting Providers

       

      
        	 	Per
      OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services
      from a provider who does not have an executed subcontract must ensure
      that  they
      have a mutually agreed upon compensation amount for the authorized service
      and notify the provider of the applicable provisions of paragraph D of OAC
      rule 5101:3-26-05.  This
      notice is provided when an MCP authorizes a non-contracting provider to
      furnish services on a one-time or infrequent basis to an MCP member
      and must include required ODJFS-model language and information. This
      notice must also be included with the transition of services
      form sent to providers as outlined
      in paragraph 29.h of Appendix
C.


      

       

                                     
e.        Integration of Member
Care

      
         

        
          	 	The MCP must ensure
      that a discharge plan is in place to meet a member’s health care
      needs following discharge from a nursing facility, and
      integrated into the member's
      continuum of care.  The
      discharge plan must address the services to be provided for the member and
      must be developed prior to the date of discharge
      from the nursing facility.   The MCP must ensure follow-up
      contact occurs with the member, or authorized representative, within
      thirty (30) days of the
      member’s discharge from the nursing facility to ensure that the member’s
      health care needs are being
met.


        

      

      


      
        
          
             


          

          
            15

            
              

            

          

          
            
              Appendix
H

              Covered
Families and Children (CFC)
population  

            

          

        

      

      


      APPENDIX
H

      


      PROVIDER
PANEL SPECIFICATIONS

      CFC
ELIGIBLE POPULATION

       

      
        	
                1.

              	
                GENERAL
      PROVISIONS

              


      

      


      MCPs must
provide or arrange for the delivery of all medically necessary, Medicaid-covered
health services, as well as assure that they meet all applicable provider panel
requirements for their entire designated service area.  The ODJFS
provider panel requirements are specified in the charts included with this
appendix and must be met prior to the MCP receiving a provider agreement with
ODJFS.  The MCP must remain in compliance with these requirements for
the duration of the provider agreement.

      


      If an MCP
is unable to provide the medically necessary, Medicaid-covered services through
their contracted provider panel, the MCP must ensure access to these services on
an as needed basis. For example, if
an MCP meets the pediatrician requirement but a member is unable to obtain a
timely appointment from a pediatrician on the MCP’s provider panel, the MCP will
be required to secure an appointment from a panel pediatrician or arrange for an
out-of-panel referral to a pediatrician.

      


      MCPs are
required to make
transportation available to any member requesting transportation when they must travel 30 miles or more
from their home to receive a medically-necessary Medicaid-covered
service.  If the MCP offers transportation to their members as an
additional benefit and this transportation benefit only covers a limited number
of trips, the required transportation listed above may not be counted toward this
trip limit (as specified in Appendix C).

      


      In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers, as well as the potential
availability of the designated provider types.  ODJFS has integrated
existing utilization patterns into the provider network requirements to avoid
disruption of care.  Most provider panel requirements are
county-specific but in certain circumstances, ODJFS requires providers to be
located anywhere in the region. Although all provider types listed in this
appendix are required provider types, only those listed on the attached charts
must be submitted for ODJFS prior approval.

      


      2.           PROVIDER
SUBCONTRACTING

      


      Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are
required to enter into fully-executed subcontracts with their
providers.  These subcontracts must include a baseline contractual
agreement, as well as the appropriate ODJFS-approved Model Medicaid Addendum.
The Model Medicaid Addendum incorporates all applicable Ohio Administrative Code
rule requirements specific to provider subcontracting and therefore cannot be
modified except to add personalizing information such as the MCP’s
name.  

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      ODJFS
must prior approve all MCP providers in the ODJFS- required provider type
categories before they can begin to provide services to that MCP’s
members.  MCPs may not employ or contract with providers excluded from
participation in Federal health care programs under either section 1128 or
section 1128A of the Social Security Act.  As part of the prior
approval process, MCPs must submit  documentation verifying that all
necessary contract documents have been appropriately completed.  ODJFS
will verify the approvability of the submission and process this information
using the ODJFS Provider Verification System (PVS) or other designated
process.  The PVS is a centralized database system that maintains
information on the status of all MCP-submitted providers.

       

      Only
those providers who meet the applicable criteria specified in this document, as
determined by ODJFS, will be approved by ODJFS.   MCPs must
credential/recredential providers in accordance with the standards specified by
the National Committee for Quality Assurance (or receive approval from ODJFS to
use an alternate industry standard) and must have completed the credentialing
review before submitting any provider to ODJFS for
approval.  Regardless of whether ODJFS has approved a provider, the
MCP must ensure that the provider has met all applicable credentialing criteria
before the provider can render services to the MCP’s members.

      


      MCPs must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.

      
        
3.           PROVIDER
PANEL REQUIREMENTS

      

      


      The
provider network criteria that must be met by each MCP are as
follows:

      


      a.           Primary Care
Providers (PCPs)

      


      Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101:
3-26-03.1.  The APN capacity can count up to 10% of the total
requirement for the county.  Acceptable specialty types for PCPs
include family/general practice, internal medicine, pediatrics, and
obstetrics/gynecology (OB/GYN).  Acceptable PCCs include FQHCs, RHCs
and the acceptable group practices/clinics specified by ODJFS.  As
part of their subcontract with an MCP, PCPs must stipulate the total Medicaid
member capacity that they can ensure for that individual MCP.

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Each PCP
must have the capacity and agree to serve at least 50 Medicaid members at each
practice site in order to be approved by ODJFS as a PCP.  The
capacity-by-site requirement must be met for all ODJFS-approved
PCPs.

       

      
        In
determining whether an MCP has sufficient PCP capacity for a region, ODJFS
considers a provider who can serve as a PCP for 2000 Medicaid MCP members
as one full-time equivalent (FTE).

        


        ODJFS
reviews the capacity totals for each PCP to determine if they appear
excessive. ODJFS reserves the right to request clarification from an MCP
for any PCP whose total stated capacity for all MCP networks added together
exceeds 2000 Medicaid members (i.e., 1 FTE) where indicated, ODJFS may set a cap
on the maximum amount of capacity that we will recognize for a specific PCP.
ODJFS may allow up to an additional 750 member capacity for each nurse
practitioner or physician’s assistant that is used to provide clinical support
for a PCP.

      

       

      For PCPs
contracting with more than one MCP, the MCP must ensure that the capacity figure
stated by the PCP in their subcontract reflects only the capacity the PCP
intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity
figure to determine if an MCP meets the provider panel requirements and this
stated capacity figure does not prohibit a PCP from actually having a caseload
that exceeds the capacity figure indicated in their subcontract.

      


      ODJFS
recognizes that MCPs will need to utilize specialty providers to serve as PCPs
for some special needs members.  Also, in some situations (e.g.,
continuity of care) a PCP may only want to serve a very small number of members
for an MCP.  In these situations it will not be necessary for the MCP
to submit these PCPs to ODJFS for prior approval.  These PCPs will not
be included in the ODJFS PVS database, or other designated process, and
therefore may not appear as PCPs in the MCP’s provider
directory.  These PCPs will, however, need to execute a subcontract
with the MCP which includes the appropriate Model Medicaid
Addendum.

      


      The PCP
requirement is based on an MCP having sufficient PCP capacity to serve 40%
of the eligibles in the region if three MCPs are serving the region and 55% of
the eligibles in the region if two MCPs are serving the region.  At a
minimum, each MCP must meet both the PCP FTE requirement for that region, and a
ratio of one PCP FTE for each 2,000 of their Medicaid members in that
region.  MCPs must also satisfy a PCP geographic accessibility
standard. ODJFS will match the PCP practice sites and the stated PCP capacity
with the geographic location of the eligible population in that region (on a
county-specific basis) and perform analysis using Geographic Information Systems
(GIS) software. The analysis will be used to determine if at least 40% of the
eligible population is located within 10 miles of PCP with available capacity in
urban counties and 40% of the eligible population within 30 miles of a PCP with
available capacity in rural counties. [Rural areas are defined pursuant to 42
CFR 412.62(f)(1)(iii).]

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      In
addition to the PCP FTE capacity requirement, MCPs must also contract with the
specified number of pediatric
PCPs for each region.  These pediatric PCPs will have their stated
capacity counted toward the PCP FTE requirement.

       

      
        A
pediatric PCP must maintain a general pediatric practice (e.g., a pediatric
neurologist would not meet this definition unless this physician also
operated a practice as a general pediatrician) at a site(s) located within the
county/region and be listed as a pediatrician with the Ohio State Medical
Board.  In addition, half of the required number of pediatric PCPs
must also be certified by the American Board of Pediatrics.  The
provider panel requirements for pediatricians are included in the practitioner
charts in this appendix.

        


        b.           Non-PCP Provider
Network

        


        In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories:  hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider types.

        


        All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their complete provider
network will include many other additional specialists and provider
types.  MCPs must ensure that all non-PCP network providers follow
community standards in the scheduling of routine appointments (i.e., the amount
of time members must wait from the time of their request to the first available
time when the visit can occur).

         

      

      Although there are currently no FTE capacity requirements of the
non-PCP required provider types, MCPs are required to ensure that adequate
access is available to members for all required provider
types.  Additionally, for certain non-PCP required provider types,
MCPs must ensure that these providers maintain a full-time practice at a site(s)
located in the specified county/region (i.e., the ODJFS-specified county
within the region or anywhere within the region if no particular county is
specified).  A full-time practice is defined as one where the provider
is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including:  consumer
satisfaction surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.

      
Hospitals - MCPs must
contract with the number and type of hospitals specified by ODJFS for each
county/region. In developing these hospital requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers and integrated the existing
utilization patterns into the hospital network requirements to avoid disruption
of care.  For this reason, ODJFS may require that MCPs contract with
out-of-state hospitals (i.e. Kentucky, West Virginia, etc.).

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      For each
Ohio hospital, ODJFS utilizes the hospital’s most current Annual Hospital
Registration and Planning Report, as filed with the Ohio Department of Health,
in verifying types of services that hospital provides.  Although ODJFS
has the authority, under certain situations, to obligate a non-contracting
hospital to provide non-emergency hospital services to an MCP’s members, MCPs
must still contract with the specified number and type of hospitals unless ODJFS
approves a provider panel exception (see Section 4 of this appendix – Provider
Panel Exceptions).

      


      If an
MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another
MCP-contracted hospital in the
specified county/region.

      


      OB/GYNs - MCPs must contract
with the specified  number of OB/GYNs for each county/region, all of
whom must maintain a full-time obstetrical practice at a site(s) located in the
specified county/region.  Only MCP-contracting OB/GYNs with current
hospital privileges at a hospital under contract with the MCP in the region can
be submitted to the PVS, or other system, count towards MCP minimum panel
requirements, and be listed in the MCPs’ provider directory.

      


      Certified Nurse Midwives (CNMs)
and Certified Nurse
Practitioners (CNPs) - MCPs must ensure access to CNM and CNP services in
the region if such provider types are present within the region.  The
MCP may contract directly with the CNM or CNP providers, or with a physician or
other provider entity who is able to obligate the participation of a CNM or
CNP.  If an MCP does not contract for CNM or CNP services and such
providers are present within the region, the MCP will be required to allow
members to receive CNM or CNP services outside of the MCP’s provider
network.

      


      Only CNMs
with hospital delivery privileges at a hospital under contract with the MCP in
the region can be submitted to the PVS, or other system, count towards MCP
minimum panel requirements, and be listed in the MCPs’ provider directory.The
MCP must ensure a member’s access to CNM and CNP services if such providers are
practicing within the region.

      


      Vision Care Providers - MCPs
must contract with the specified number of ophthalmologists/optometrists for
each specified county/region , all of whom must maintain a full-time practice at
a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams. (MCPs will be expected to
contract with an adequate number of ophthalmologists as part of their overall
provider panel, but only ophthalmologists who regularly perform routine eye
exams can be used to meet the vision care provider panel requirement.) If
optical dispensing is not sufficiently available in a region through the MCP’s
contracting ophthalmologists/optometrists, the MCP must separately contract with
an adequate number of optical dispensers located in the region.

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        Dental Care Providers -
MCPs must contract with the specified number of dentists. In order to assure
sufficient access
to adult MCP members, no more than two-thirds of the dentists used to meet
the provider panel
requirement may be pediatric dentists.

      

      


      Federally Qualified Health
Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are
required to ensure member access to any  federally qualified health
center or rural health clinic (FQHCs/RHCs), regardless of contracting
status.  Contracting FQHC/RHC providers must be submitted for ODJFS
approval via the PVS process, or other designated process.  Even if
no FQHC/RHC is available within the region, MCPs must have mechanisms in
place to ensure coverage for FQHC/RHC services in the event that a member
accesses these services outside of the region. 

      


      In order
to ensure that any FQHC/RHC has the ability to submit a claim to ODJFS for
the state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement
pursuant to the following:

      


      
        	
                 
      

              	
                •

              	
                MCPs
      must provide expedited reimbursement on a service-specific basis in an
      amount no less than the payment made to other providers for the same or
      similar service.

              


      

      


      
        	
                 
      

              	
                •

              	
                If
      the MCP has no comparable service-specific rate structure, the MCP must
      use the regular Medicaid fee-for-service payment schedule for
      non-FQHC/RHC providers.

              


      

      


      
        	
                 
      

              	
                •

              	
                MCPs
      must make all efforts to pay FQHCs/RHCs as quickly as possible and not
      just attempt to pay these claims within the prompt pay time
      frames.

              


      

       

      
        MCPs are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.

      

      


      Qualified Family Planning Providers
(QFPPs) - All MCP members must be permitted to self-refer to family
planning services provided by a QFPP.  A QFPP is defined as any public
or not-for-profit health care provider that complies with Title X
guidelines/standards, and receives either
Title X funding or family planning funding from the Ohio Department of
Health.  MCPs must reimburse all medically-necessary Medicaid-covered
family planning services provided to eligible members by a QFPP provider
(including on-site pharmacy and diagnostic services) on a patient
self-referral basis, regardless of the provider’s status as a panel or non-panel
provider.

      


      MCPs will
be required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider confidentiality,
and convey pertinent
information to the member’s PCP and/or MCP.

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Behavioral Health Providers –
MCPs must assure member access to all Medicaid-covered behavioral health
services for members as specified in Appendix G.b.ii.  Although ODJFS
is aware that certain outpatient substance abuse services may only be available
through Medicaid providers certified by  the Ohio Department of Drug
and Alcohol Addiction Services  (ODADAS)  in some areas,
MCPs must maintain an adequate number of contracted mental health providers in
the region to assure access for members who are unable to timely
access services or unwilling to access services through community mental health
centers.  MCPs are advised
not to contract with community mental health centers as all services they
provide to MCP members are to be billed to ODJFS.

       

      Other Specialty
Types (pediatricians,
general surgeons, otolaryngologists, allergists, andorthopedists) - MCPs
must contract with the specified number of all other ODJFS designated specialty
provider types. In order to be counted toward meeting the provider panel
requirements, these specialty providers must maintain a full-time practice at a
site(s) located within the specified county/region. Only contracting general
surgeons, orthopedists, and otolaryngologists with admitting privileges at a
hospital under contract with the MCP in the region can be submitted to the PVS,
or other system, count towards MCP minimum panel requirements, and be listed in
the MCPs’ provider directory.

       

      4.           PROVIDER PANEL
EXCEPTIONS

      


      ODJFS may
specify provider panel criteria for a service area that deviates from that
specified in this appendix if:

      


      
        	
                 
      

              	
                -

              	
                the
      MCP presents sufficient documentation to ODJFS to verify that they have
      been unable to meet or maintain certain provider panel requirements in a
      particular service area despite all reasonable efforts on their part to
      secure such a contract(s), and

              


      

      


      
        	
                 
      

              	
                -

              	
                if
      notified by ODJFS, the provider(s) in question fails to provide a
      reasonable argument why they would not contract with the MCP,
      and

              


      

       

              
     - 
         the MCP presents sufficient
assurances to ODJFS that their members will have adequate access to the services
in question.

      


      If an MCP
is unable to contract with or maintain a sufficient number of providers to meet
the ODJFS-specified provider panel criteria, the MCP may request an exception to
these criteria by submitting a provider panel exception request as specified by
ODJFS.  ODJFS will review the exception request and determine whether
the MCP has sufficiently demonstrated that all

      reasonable
efforts were made to obtain contracts with providers of the type in question and
that they will be able to provide access to the services in
question.

       

      
        
          
          

        

        
          7

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      A
provider panel exception request (PPE) may be approved for a period of not more
than one year.  Approvals shall have an effective date of the 1st day
of the month in which the PPE is approved by ODJFS.   ODJFS will
not accept or review a request to extend the effective date of a PPE that is
submitted earlier than 15 calendar days prior to the date of expiration. Once
the MCP has resolved the deficiency, the PPE is no longer valid.  If
the MCP becomes deficient in the same area a new PPE request will need to be
submitted prior to the next compliance review.

      


      ODJFS
will aggressively monitor access to all services related to the approval of a
provider panel exception request through a variety of data sources, including:
consumer satisfaction surveys; member appeals/grievances/complaints and state
hearing notifications/requests; member just-cause for termination requests;
clinical quality studies; encounter data volume; provider complaints, and
clinical performance measures.  ODJFS approval of a provider panel
exception request does not exempt the MCP from assuring access to the services
in question.  If ODJFS determines that an MCP has not provided
sufficient access to these services, the MCP may be subject to
sanctions.

       

      
        	
                5.

              	
                PROVIDER
      DIRECTORIES

              


      

      
MCP
provider directories must include all MCP-contracted providers [except as
specified by ODJFS] as well as certain non-contracted providers.  At
the time of ODJFS’ review, the information listed in the MCP’s provider
directory for all ODJFS-required provider types specified on the attached charts
must exactly match the data currently on file in the ODJFS PVS, or other designated
process.

      


      MCP
provider directories must utilize a format specified by ODJFS. Directories may
be region-specific or include multiple regions, however, the providers within
the directory must be divided by region, county, and provider type, in that
order.

      


      The
directory must also specify:

      


      
        	
                 
      

              	
                •

              	
                provider
      address(es) and phone number(s);

              
	 	
                • 

              	an
      explanation of how to access providers (e.g. referral required vs.
      self-referral);
	 	
                • 

              	an
      indication of which providers are available to members on a self-referral
      basis


      

      
        	
                 
      

              	
                •

              	
                foreign-language
      speaking PCPs and specialists and the specific foreign language(s) spoken;
      

              


      

      
      

      
        	
                 
      

              	
                •

              	
                how
      members may obtain directory information in alternate formats that takes
      into consideration the special needs of eligible individuals including but
      not limited to,

              


      

      
      

      
        	
                 
      

              	
                visually-limited,
      LEP, and LRP eligible individuals;
and

              


      

      
        	
                 
      

              	
                •

              	
                any
      PCP or specialist practice
limitations.

              


      

       

      
        
          
          

        

        
          8

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Printed Provider
Directory

      Prior to
receiving a provider agreement, all MCPs must develop a printed provider
directory that shall be prior-approved by ODJFS for each covered
population.  For example, an MCP who serves
CFC and ABD in the Central Region would have two provider directories, one for
CFC and one for ABD. Once approved, this directory may be regularly updated
with provider additions or deletions by the MCP without ODJFS prior-approval,
however, copies of the revised directory (or inserts) must be submitted to ODJFS
prior to distribution to members.

       

      On a
quarterly basis, MCPs must
create an insert to each printed directory that lists those
providers deleted from
the MCP’s provider panel during the previous three
months.  Although

      this
insert does not need to be prior approved by ODJFS, copies of the insert must be
submitted to ODJFS two weeks prior to distribution to members.

      


      Internet Provider
Directory

      MCPs are
required to have an internet-based provider directory available in the same
format as their ODJFS-approved printed directory.  This internet
directory must allow members to

      
        electronically
search for MCP panel providers based on name, provider type, and geographic
proximity, and population (e.g. CFC and/or ABD).  If an MCP has one
internet-based directory for multiple populations, each provider must include a
description of which population they serve.

         

        
          The
internet directory may be updated at any time to include providers who are not one of the ODJFS-required
provider types listed on the charts included with this
appendix.  ODJFS-required providers must be added to the internet
directory within one week of the MCP’s notification of ODJFS-approval of the
provider via the Provider Verification
process.  Providers

          being
deleted from the MCP’s panel must deleted from the internet directory within one
week of notification from the provider to the MCP. Providers being deleted
from the MCP’s panel must be posted to the internet directory within one week of
notification from the provider to the MCP of the deletion.  These
deleted providers must be included in the inserts to the MCP’s provider
directory referenced above.

        

      

       

      
        
          
          

        

        
          9

          
            

          

        

        
          
            Appendix
H

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                6
      .

              	
                FEDERAL ACCESS
      STANDARDS

              


      

      


      MCPs must
demonstrate that they are in compliance with the following federally
defined  provider panel access standards as required by 42 CFR
438.206:

      


      In
establishing and maintaining their provider panel, MCPs must consider the
following:

      


      
        	
                
                  • 
      

                

              	
                
                  The
      anticipated Medicaid membership.

                

              	
                 

              


      

      
        	
                •

              	
                The
      expected utilization of services, taking into consideration the
      characteristics and health care needs of specific Medicaid populations
      represented in the MCP.

              


      

      
        	
                •

              	
                The
      number and types (in terms of training, experience, and specialization) of
      panel providers required to deliver the contracted Medicaid
      services.

              


      

      
        	
                •

              	
                The
      geographic location of panel providers and Medicaid members, considering
      distance, travel time, the means of transportation ordinarily used by
      Medicaid members, and whether the location provides physical access for
      Medicaid members with disabilities.

              


      

      
        	
                •

              	
                MCPs
      must adequately and timely cover services to an out-of-network provider if
      the
      MCP’s contracted provider panel is unable to provide the services covered
      under the MCP’s provider agreement.  The MCP must cover the
      out-of-network services for as long as the MCP network is unable to
      provide the services. MCPs must coordinate with the out-of-network
      provider with respect to payment and ensure that the provider agrees with
      the applicable requirements.

              	
                 

              


      

       

      
        Contracting
providers must offer hours of operation that are no less than the hours of
operation offered to commercial members or comparable to Medicaid
fee-for-service, if the provider serves only Medicaid members.  MCPs
must ensure that services are available 24 hours a day, 7 days a week, when
medically necessary.  MCPs must establish mechanisms to ensure that
panel providers comply with timely access requirements, and must take corrective
action if there is failure to comply.

      

       

      In order
to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and
438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
specified by ODJFS, that demonstrates it offers an appropriate range of
preventive, primary care and specialty services adequate for the anticipated
number of members in the service area, while maintaining a provider panel that
is sufficient in number, mix, and geographic distribution to meet the needs of
the number of members in the service area.

      


      This
documentation of assurance of adequate capacity and services must be submitted
to ODJFS no less frequently than at the time the MCP enters into a contract with
ODJFS; at any time there is a significant change (as defined by
ODJFS)  in the MCP’s operations that would affect adequate capacity
and services (including changes in services, benefits, geographic service or
payments); and at any time there is enrollment of a new population in the
MCP.

      


      
        
          
             


          

          
            10

            
              

            

          

          
            
              
                 

              

            

          

        

      

       

      
        
          	
                  North East Region -
      Hospitals

                


        

         

         

      

      
        	
                Minimum
      Provider Panel Requirements

              
	 
      	
                Total
      Required Hospitals

              	
                Ashtabula

              	
                Cuyahoga

              	
                Erie

              	
                Geauga

              	
                Huron

              	
                Lake

              	
                Lorain

              	
                Medina

              	
                Additional
      Required Hospitals: Out-of-Region

              
	
                General
      Hospital1

              	
                8
      2

              	
                1

              	
                1
      2

              	
                1

              	
                1

              	
                1

              	
                1

              	
                1

              	
                1

              	 
      
	
                Hospital
      System

              	
                1

              	 
      	
                1

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      


      

      


      
        	
                1  These
      hospitals must provide obstetrical services if such a hospital is
      available in the county/region.

              	 
      	 
      	 
      	 
      	 
      
	
                2
      The Cuyahoga hospital requirement may be met by either contracting
      with (1) a single
      hospital system that includes fifty (50) pediatric beds and five (5)
      pediatric intensive care unit (PICU) beds OR (2) a single general hospital
      that includes fifty (50) pediatric beds and five (5) pediatric intensive
      care unit (PICU) beds and a hospital
system.

              


      

      


      
        
          
             


          

          
             

            
              

            

          

          
            
               

            

          

        

      

      


      
        North East Central Region - Hospitals

      

      


      
        	
                Minimum
      Provider Panel Requirements

              
	 
      	
                Total
      Required Hospitals

              	
                Columbiana

              	
                Mahoning

              	
                Trumbull

              	
                Additional
      Required Hospitals: Out-of-Region

              
	
                General
      Hospital1

              	
                3

              	
                1

              	
                1 2

              	
                1

              	 
      
	
                 Hospital System

              	 	 	 	 	 


      

    

     

    
      
        	
                1  These
      hospitals must provide obstetrical services if such a hospital is
      available in the county/region, except where a hospital must meet the
      criteria specified in footnote #4 below.

              	 
      
	
                2   Must
      be a hospital that includes thirty (30) pediatric beds and  five
      (5) pediatric intensive care unit (PICU) beds.

              	 
      	 
      	 
      


      


      
        
           


        

        
           

          
            

          

        

        
          
             

          

        

      

    

    

      East Central Region -
Hospitals

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	 
      	
                  Total
      Required Hospitals

                	
                  Ashland

                	
                  Carroll

                	
                  Holmes

                	
                  Portage

                	
                  Richland

                	
                  Stark

                	
                  Summit

                	
                  Tuscarawas

                	
                  Wayne

                	
                  Additional
      Required Hospitals: Out-of-Region

                
	
                  General
      Hospital1

                	
                  8

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1

                	
                  1

                	
                  1 2

                	
                  1

                	
                  1

                	 
      
	
                  Hospital
      System

                	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      


        

      

       

      
        	
                1  These
      hospitals must provide obstetrical services if such a hospital is
      available in  the county/region, except where a hospital must
      meet the criteria specified in footnote #4 below.

              
	
                2   Must
      be a hospital that includes one hundred (100) pediatric beds and five (5)
      pediatric intensive care unit (PICU) beds.

              	 
      	 
      	 
      	 
      	 
      


      

    

     

    
      
        
          
             


          

          
             

            
              

            

          

          
            
               

            

          

        

      

      


      
        South East Region -
Hospitals

         

         

        
          
            	
                    Minimum
      Provider Panel Requirements

                  
	 
      	
                    Total
      Required Hospitals

                  	
                    Athens

                  	
                    Belmont

                  	
                    Coshocton

                  	
                    Gallia

                  	
                    Guernsey

                  	
                    Harrison

                  	
                    Jackson

                  	
                    Jefferson

                  	
                    Lawrence

                  	
                    Meigs

                  	
                    Monroe

                  	
                    Morgon

                  	
                    Muskingum

                  	
                    Noble

                  	
                    Vinton

                  	
                    Washington

                  	
                    Additional
      Required Hospitals: Out-of-Region

                  
	
                    General
      Hospital1

                  	
                    11

                  	
                    1

                  	
                    1

                  	
                    1

                  	
                    1

                  	
                    1

                  	 
      	 
      	
                    1

                  	 
      	 
      	 
      	 
      	
                    1

                  	 
      	 
      	
                    1

                  	
                    Cabell
      AND King's
      Daughter AND Children's Hospital
      Columbus

                  
	
                    Hospital
      System

                  	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


          

        

         

      

      1   These hospitals must provide obsetrical services if
such a hospital is available in the
county/region.

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      
        Central Region -
Hospitals

         

      

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	 
      	
                  Total
      Required Hospitals

                	
                  Crawford

                	
                  Delaware

                	
                  Fairfield

                	
                  Fayette

                	
                  Franklin

                	
                  Hocking

                	
                  Knox

                	
                  Licking

                	
                  Logan

                	
                  Madison

                	
                  Marion

                	
                  Morrow

                	
                  Perry

                	
                  Pickaway

                	
                  Pike

                	
                  Ross

                	
                  Scioto

                	
                  Union

                	
                  Additional
      Required Hospitals: Out-of-Region

                
	
                  General
      Hospital1

                	
                  14

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1 2

                	 
      	
                  1

                	
                  1

                	
                  1

                	
                  1

                	
                  1

                	 
      	 
      	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1

                	
                  Genesis
      Health Care System, Inc.

                
	
                  Hospital
      System

                	
                  2

                	 
      	 
      	 
      	 
      	
                  2

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          	
                  1  These
      hospitals must provide obstetrical services if such a hospital is
      available in  the county/region, except where a hospital must
      meet the criteria specified in footnote #4 below.

                
	
                  2   Must
      be a hospital that includes one hundred fifty (150) pediatric beds and
      twenty-five (25) pediatric intensive care unit (PICU)
beds.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      
        South West Region -
Hospitals

         

         

        
          
            	
                    Minimum
      Provider Panel Requirements

                  
	 
      	
                    Total
      Required Hospitals

                  	
                    Adams

                  	
                    Brown

                  	
                    Butler

                  	
                    Clermont

                  	
                    Clinton

                  	
                    Hamilton

                  	
                    Highland

                  	
                    Warren

                  	
                    Additional
      Required Hospitals: Out-of-Region

                  
	
                    General
      Hospital1

                  	
                    6

                  	 
      	
                    1

                  	
                    1

                  	 
      	
                    1

                  	
                    1 2

                  	
                    1

                  	 
      	
                    Grandview
      or Miami
      Valley

                  
	
                    Hospital
      System

                  	
                    2

                  	 
      	 
      	 
      	 
      	 
      	
                    2

                  	 
      	 
      	 
      


          

        

         

      

      
        
          	
                  1  These
      hospitals must provide obstetrical services if such a hospital is
      available in the county/region, except where a hospital must meet the
      criteria specified in footnote #4 below.

                
	
                  2   Must
      be a hospital that includes two-hundred  (200) pediatric beds
      and thirty-five (35) pediatric intensive care unit (PICU)
      beds.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      
        West Central Region -
Hospitals

      

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	 
      	
                  Total
      Required Hospitals

                	
                  Champaign

                	
                  Clark

                	
                  Darke

                	
                  Greene

                	
                  Miami

                	
                  Montgomery

                	
                  Preble

                	
                  Shelby

                	
                  Additional
      Required Hospitals: Out-of-Region

                
	
                  General
      Hospital1

                	
                  6

                	 
      	
                  1

                	
                  1

                	
                  1

                	
                  1

                	
                  1
      2

                	 
      	
                  1

                	 
      
	
                  Hospital
      System

                	
                  1

                	 
      	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      


        

      

       

      
        
          	
                  1  These
      hospitals must provide obsetrical services if such a hospital is available
      in the county/region, except where a hospital must meet the criteria
      specified in footnote #4 below.

                
	
                  2  Must
      be a hospital that includes seventy-five (75) pediatric beds and ten
      (10) pediatric intensive care unit (PICU) beds.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      
        North West Region -
Hospitals

      

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	 
      	
                  Total
      Required Hospitals

                	
                  Allen

                	
                  Auglaize

                	
                  Defiance

                	
                  Fulton

                	
                  Hancock

                	
                  Hardin

                	
                  Henry

                	
                  Lucas

                	
                  Mercer

                	
                  Ottawa

                	
                  Paulding

                	
                  Putnam

                	
                  Sandusky

                	
                  Seneca

                	
                  Van
      Wert

                	
                  Williams

                	
                  Wood

                	
                  Wyandot

                	
                  Additional
      Required Hospitals: Out-of-Region

                
	
                  General
      Hospital1

                	
                  10

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	
                  1

                	
                  1

                	 
      	
                  1

                	
                  Bellevue
      Hospital Association

                
	
                  Hospital
      System

                	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  1 2

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          	
                  1  These
      hospitals must provide obsetrical services if such a hospital is available
      in   the county/region.

                	 
      	 
      
	
                  2  Must
      be a hospital system that includes forty-five (45) pediatric beds and ten
      (10) pediatric intensive care unit (PICU) beds.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      North
East Region - PCP Capacity

       

       

      
        
          	
                  Minimum PCP Capacity
      Requirements

                
	
                  PCPs

                	
                  Total
      Required

                	
                  Ashtabula

                	
                  Cuyahoga

                	
                  Erie

                	
                  Geauga

                	
                  Huron

                	
                  Lake

                	
                  Lorain

                	
                  Medina

                	
                  Additional
      Required: In-Region
  *

                
	
                  Capacity
      1

                	
                  98,212

                	
                  5,256

                	
                  66,564

                	
                  2,873

                	
                  1,111

                	
                  2,612

                	
                  5,210

                	
                  11,431

                	
                  3,155

                	 
      
	
                  FTEs

                	
                  49.11

                	
                  2.63

                	
                  33.28

                	
                  1.44

                	
                  0.56

                	
                  1.31

                	
                  2.61

                	
                  5.72

                	
                  1.58

                	 
      


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

       

       North
East Central Region - PCP Capacity 

       

       

      
        
          	
                  Minimum PCP Capacity
      Requirements

                
	
                  PCPs

                	
                  Total
      Required

                	
                  Columbiana

                	
                  Mahoning

                	
                  Trumbull

                	
                  Additional
      Required: In-Region
  *

                
	
                  Capacity
      1

                	
                  31,367

                	
                  5,281

                	
                  12,039

                	
                  9,047

                	
                  5,000

                
	
                  FTEs

                	
                  15.68

                	
                  2.64

                	
                  6.02

                	
                  4.52

                	
                  2.50

                


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      East
Central Region - PCP Capacity

       

       

      
        
          	
                  Minimum
      PCP Capacity Requirements

                
	
                  PCPs

                	
                  Total
      Required

                	
                  Ashland

                	
                  Carroll

                	
                  Holmes

                	
                  Portage

                	
                  Richland

                	
                  Stark

                	
                  Summit

                	
                  Tuscarawas

                	
                  Wayne

                	
                  Additional
      Required:     In-Region
      *

                
	
                  Capacity
      1

                	
                  55,006

                	
                  1,732

                	
                  1,226

                	
                  794

                	
                  4,329

                	
                  5,363

                	
                  14,376

                	
                  20,279

                	
                  3,616

                	
                  3,291

                	 
      
	
                  FTEs

                	
                  27.50

                	
                  0.87

                	
                  0.61

                	
                  0.40

                	
                  2.16

                	
                  2.68

                	
                  7.19

                	
                  10.14

                	
                  1.81

                	
                  1.65

                	 
      


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      Central
Region - PCP Capacity

       

       

      
        
          	
                  County

                	
                  Capacity
      1

                	
                  FTEs

                
	 
      	 
      	 
      
	
                  Total
      Required

                	
                  100,253

                	
                  50.13

                
	
                  Crawford

                	
                  2,016

                	
                  1.01

                
	
                  Delaware

                	
                  2,307

                	
                  1.15

                
	
                  Fairfield

                	
                  4,698

                	
                  2.35

                
	
                  Fayette

                	
                  1,341

                	
                  0.67

                
	
                  Franklin

                	
                  55,101

                	
                  27.55

                
	
                  Hocking

                	
                  1,672

                	
                  0.84

                
	
                  Knox

                	
                  2,236

                	
                  1.12

                
	
                  Licking

                	
                  5,897

                	
                  2.95

                
	
                  Logan

                	
                  1,656

                	
                  0.83

                
	
                  Madison

                	
                  1,378

                	
                  0.69

                
	
                  Marion

                	
                  3,042

                	
                  1.52

                
	
                  Morrow

                	
                  1,492

                	
                  0.75

                
	
                  Perry

                	
                  2,263

                	
                  1.13

                
	
                  Pickaway

                	
                  2,123

                	
                  1.06

                
	
                  Pike

                	
                  2,116

                	
                  1.06

                
	
                  Ross

                	
                  4,442

                	
                  2.22

                
	
                  Scioto

                	
                  5,204

                	
                  2.60

                
	
                  Union

                	
                  1,269

                	
                  0.63

                


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      South
East Region - PCP Capacity

       

       

      
        
          	
                  County

                	
                  Capacity
      1

                	
                  FTEs

                
	 
      	 
      	 
      
	
                  Total
      Required

                	
                  53,000

                	
                  26.50

                
	
                  Athens

                	
                  2,664

                	
                  1.33

                
	
                  Belmont

                	
                  3,178

                	
                  1.59

                
	
                  Coshocton

                	
                  1,840

                	
                  0.92

                
	
                  Gallia

                	
                  1,918

                	
                  0.96

                
	
                  Guernsey

                	
                  2,518

                	
                  1.26

                
	
                  Harrison

                	
                  810

                	
                  0.41

                
	
                  Jackson

                	
                  2,107

                	
                  1.05

                
	
                  Jefferson

                	
                  3,418

                	
                  1.71

                
	
                  Lawrence

                	
                  4,021

                	
                  2.01

                
	
                  Meigs

                	
                  1,557

                	
                  0.78

                
	
                  Monroe

                	
                  750

                	
                  0.38

                
	
                  Morgon

                	
                  930

                	
                  0.47

                
	
                  Muskingum

                	
                  5,304

                	
                  2.65

                
	
                  Noble

                	
                  581

                	
                  0.29

                
	
                  Vinton

                	
                  1,061

                	
                  0.53

                
	
                  Washington

                	
                  2,755

                	
                  1.38

                
	
                  Additional
      Required: In-Region *

                	
                  7,000

                	
                  3.50

                


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      South
West Region - PCP Capacity

       

       

      
        
          	
                  Minimum
      PCP Capacity Requirements

                
	
                  PCPs

                	
                  Total
      Required

                	
                  Adams

                	
                  Brown

                	
                  Butler

                	
                  Clermont

                	
                  Clinton

                	
                  Hamilton

                	
                  Highland

                	
                  Warren

                	
                  Additional
      Required: In-Region
  *

                
	
                  Capacity
      1

                	
                  58,754

                	
                  2,063

                	
                  2,122

                	
                  12,296

                	
                  5,787

                	
                  1,705

                	
                  29,787

                	
                  2,240

                	
                  2,754

                	 
      
	
                  FTEs

                	
                  29.38

                	
                  1.03

                	
                  1.06

                	
                  6.15

                	
                  2.89

                	
                  0.85

                	
                  14.89

                	
                  1.12

                	
                  1.38

                	 
      


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      West
Central Region - PCP Capacity

       

       

      
        
          	
                  Minimum
      PCP Capacity Requirements

                
	
                  PCPs

                	
                  Total
      Required

                	
                  Champaign

                	
                  Clark

                	
                  Darke

                	
                  Greene

                	
                  Miami

                	
                  Montgomery

                	
                  Preble

                	
                  Shelby

                	
                  Additional
      Required: In-Region
  *

                
	
                  Capacity
      1

                	
                  42,784

                	
                  1,472

                	
                  7,225

                	
                  1,476

                	
                  4,347

                	
                  2,550

                	
                  22,751

                	
                  1,541

                	
                  1,422

                	 
      
	
                  FTEs

                	
                  21.39

                	
                  0.74

                	
                  3.61

                	
                  0.74

                	
                  2.17

                	
                  1.28

                	
                  11.38

                	
                  0.77

                	
                  0.71

                	 
      


        

      

       

      
        
          	
                  1  Based
      on an FTE of 2000 members

                	 
      	 
      	 
      	 
      
	
                  *
      Must be located within the region.

                	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      North
West Region - PCP Capacity

       

       

      
        
          	
                  County

                	
                  Capacity
      1

                	
                  FTEs

                
	 
      	 
      	 
      
	
                  Total
      Required

                	
                  68,540

                	
                  34.27

                
	
                  Allen

                	
                  4,262

                	
                  2.13

                
	
                  Auglaize

                	
                  1,228

                	
                  0.61

                
	
                  Defiance

                	
                  1,555

                	
                  0.78

                
	
                  Fulton

                	
                  1,270

                	
                  0.64

                
	
                  Hancock

                	
                  2,038

                	
                  1.02

                
	
                  Hardin

                	
                  1,096

                	
                  0.55

                
	
                  Henry

                	
                  894

                	
                  0.45

                
	
                  Lucas

                	
                  24,752

                	
                  12.38

                
	
                  Mercer

                	
                  821

                	
                  0.41

                
	
                  Ottawa

                	
                  1,271

                	
                  0.64

                
	
                  Paulding

                	
                  710

                	
                  0.36

                
	
                  Putnam

                	
                  770

                	
                  0.39

                
	
                  Sandusky

                	
                  2,142

                	
                  1.07

                
	
                  Seneca

                	
                  2,128

                	
                  1.06

                
	
                  Van
      Wert

                	
                  847

                	
                  0.42

                
	
                  Williams

                	
                  1,478

                	
                  0.74

                
	
                  Wood

                	
                  2,444

                	
                  1.22

                
	
                  Wyandot

                	
                  634

                	
                  0.32

                
	
                  Additional
      Required: In-Region *

                	
                  18,200

                	
                  9.10

                


        

      

       

      
        1  Based
on an FTE of 2000 members

        
          * Must be
located within the region.

        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      North
East Region - Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Ashtabula

                	
                  Cuyahoga

                	
                  Erie

                	
                  Geauga

                	
                  Huron

                	
                  Lake

                	
                  Lorain

                	
                  Medina

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  90

                	
                  1

                	
                  66

                	
                  2

                	 
      	 
      	
                  3

                	
                  8

                	
                  3

                	
                  7

                
	
                  OB/GYNs

                	
                  25

                	
                  1

                	
                  16

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  2

                	
                  1

                	
                  2

                
	
                  Vision

                	
                  33

                	
                  1

                	
                  25

                	
                  1

                	 
      	 
      	
                  1

                	
                  2

                	
                  1

                	
                  2

                
	
                  General
      Surgeons

                	
                  20

                	 
      	
                  12

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  2

                	
                  1

                	
                  2

                
	
                  Otolaryngologist

                	
                  6

                	 
      	
                  2

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	
                  3

                
	
                  Allergists

                	
                  5

                	 
      	
                  2

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	
                  2

                
	
                  Orthopedists

                	
                  16

                	 
      	
                  8

                	
                  1

                	 
      	 
      	
                  1

                	
                  2

                	
                  1

                	
                  3

                
	
                  Dentists5

                	
                  89

                	
                  2

                	
                  65

                	
                  1

                	
                  1

                	
                  1

                	
                  5

                	
                  10

                	
                  3

                	
                  1

                


        

      

      
        
          	
                   

                  1
      All required providers must be located within the
  region.

                
	
                  2
      Additional required providers may be located anywhere within the
      region.

                
	
                  3
      Preferred Providers are the additional provider contracts that must
      be secured in order for the MCP to receive bonus
      points.

                
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      North
East Central - Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Columbiana

                	
                  Mahoning

                	
                  Trumbull

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  23

                	
                  2

                	
                  10

                	
                  6

                	
                  5

                
	
                  OB/GYNs

                	
                  7

                	
                  1

                	
                  3

                	
                  2

                	
                  1

                
	
                  Vision

                	
                  7

                	 
      	
                  3

                	
                  2

                	
                  2

                
	
                  General
      Surgeons

                	
                  6

                	
                  1

                	
                  3

                	
                  1

                	
                  1

                
	
                  Otolaryngologist

                	
                  2

                	 
      	
                  1

                	 
      	
                  1

                
	
                  Allergists

                	
                  1

                	 
      	 
      	 
      	
                  1

                
	
                  Orthopedists

                	
                  4

                	 
      	
                  2

                	
                  1

                	
                  1

                
	
                  Dentists5

                	
                  23

                	
                  2

                	
                  11

                	
                  8

                	
                  2

                
	 
      	 
      	 
      	 
      	 
      	 
      
	
                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                	 
      
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                	 
      
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                	 
      
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      East
Central - Practitioners

       

       

      
        
          
            	
                    Minimum
      Provider Panel Requirements

                  
	
                    Provider
      Types

                  	
                    Total
      Required Providers1

                  	
                    Ashland

                  	
                    Carroll

                  	
                    Holmes

                  	
                    Portage

                  	
                    Richland

                  	
                    Stark

                  	
                    Summit

                  	
                    Tuscarawas

                  	
                    Wayne

                  	
                    Additional
      Required 

                    Providers2

                  
	
                    Pediatricians4

                  	
                    49

                  	
                    1

                  	 
      	 
      	
                    2

                  	
                    3

                  	
                    #

                  	
                    #

                  	
                    2

                  	
                    2

                  	
                    5

                  
	
                    OB/GYNs

                  	
                    17

                  	 
      	 
      	 
      	 
      	
                    1

                  	
                    5

                  	
                    8

                  	 
      	
                    1

                  	
                    2

                  
	
                    Vision

                  	
                    18

                  	 
      	 
      	 
      	 
      	
                    1

                  	
                    5

                  	
                    8

                  	 
      	 
      	
                    4

                  
	
                    General
      Surgeons

                  	
                    13

                  	 
      	 
      	 
      	
                    1

                  	
                    2

                  	
                    3

                  	
                    4

                  	
                    1

                  	
                    1

                  	
                    1

                  
	
                    Otolaryngologist

                  	
                    7

                  	 
      	 
      	 
      	 
      	 
      	
                    2

                  	
                    2

                  	 
      	 
      	
                    3

                  
	
                    Allergists

                  	
                    3

                  	 
      	 
      	 
      	 
      	 
      	
                    1

                  	
                    1

                  	 
      	 
      	
                    1

                  
	
                    Orthopedists

                  	
                    9

                  	 
      	 
      	 
      	 
      	
                    1

                  	
                    2

                  	
                    2

                  	 
      	
                    1

                  	
                    3

                  
	
                     Dentists5     

                  	
                     48

                  	
                    2

                  	 	 	
                    3 

                  	
                    5 

                  	
                    13

                  	
                     17

                  	
                     3

                  	
                    3

                  	
                    2 

                  
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    1
      All required providers must be located within the region.

                  	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    2
      Additional required providers may be located anywhere within the
      region.

                  	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                    3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                  	 
      	 
      	 
      
	
                    4
      Half of this number must be certified by the American Board of
      Pediatrics.

                  	 
      	 
      	 
      	 
      	 
      	 
      
	
                    5 No
      more than two-thirds of this number can be pediatric
    dentists.

                  	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


          
 

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      South
East  - Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      

                  Types

                	
                  Total
      Required Providers1

                	
                  Athens

                	
                  Belmont

                	
                  Coshocton

                	
                  Gallia

                	
                  Guernsey

                	
                  Harrison

                	
                  Jackson

                	
                  Jefferson

                	
                  Lawrence

                	
                  Meigs

                	
                  Monroe

                	
                  Morgon

                	
                  Muskingum

                	
                  Noble

                	
                  Vinton

                	
                  Washington

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  31

                	
                  1

                	
                  1

                	 
      	
                  2

                	
                  1

                	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  2

                	 
      	 
      	
                  1

                	
                  22

                
	
                  OB/GYNs

                	
                  9

                	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	
                  4

                
	
                  Vision

                	
                  13

                	
                  1

                	
                  1

                	 
      	
                  1

                	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1

                	 
      	 
      	 
      	
                  2

                	 
      	 
      	
                  1

                	
                  3

                
	
                  General
      Surgeons

                	
                  8

                	 
      	
                  1

                	 
      	
                  1

                	
                  1

                	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	
                  2

                
	
                  Otolaryngolo-gist

                	
                  3

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	
                  1

                
	
                  Allergists

                	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                
	
                  Orthopedists

                	
                  5

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  4

                
	
                  Dentists5

                	
                  30

                	
                  2

                	
                  3

                	
                  1

                	
                  1

                	
                  3

                	 
      	
                  1

                	
                  3

                	
                  2

                	 
      	 
      	 
      	
                  3

                	 
      	 
      	
                  2

                	
                  9

                
	
                   

                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                	 
      	 
      	 
      	 
      	 
      
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      Central
- Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Crawford

                	
                  Delaware

                	
                  Fairfield

                	
                  Fayette

                	
                  Franklin

                	
                  Hocking

                	
                  Knox

                	
                  Licking

                	
                  Logan

                	
                  Madison

                	
                  Marion

                	
                  Morrow

                	
                  Perry

                	
                  Pickaway

                	
                  Pike

                	
                  Ross

                	
                  Scioto

                	
                  Union

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  86

                	 
      	
                  4

                	
                  3

                	 
      	
                  55

                	 
      	
                  1

                	
                  2

                	
                  1

                	
                  1

                	
                  2

                	 
      	 
      	
                  1

                	 
      	
                  2

                	
                  2

                	
                  1

                	
                  11

                
	
                  OB/GYNs

                	
                  24

                	 
      	
                  2

                	
                  2

                	 
      	
                  12

                	 
      	
                  1

                	
                  1

                	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  1

                	
                  1

                	 
      	
                  3

                
	
                  Vision

                	
                  31

                	
                  1

                	
                  2

                	
                  2

                	 
      	
                  15

                	 
      	
                  1

                	
                  1

                	
                  1

                	 
      	
                  1

                	 
      	 
      	
                  1

                	 
      	
                  1

                	
                  1

                	
                  1

                	
                  3

                
	
                  General
      Surgeons

                	
                  22

                	
                  1

                	
                  1

                	
                  1

                	 
      	
                  10

                	 
      	
                  1

                	
                  1

                	
                  1

                	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  1

                	
                  1

                	
                  1

                	
                  2

                
	
                  Otolaryngologist

                	
                  6

                	 
      	
                  1

                	 
      	 
      	
                  4

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                
	
                  Allergists

                	
                  4

                	 
      	 
      	 
      	 
      	
                  2

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  2

                
	
                  Orthopedists

                	
                  13

                	 
      	 
      	
                  1

                	 
      	
                  7

                	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  2

                
	
                  Dentists5

                	
                  77

                	
                  1

                	
                  2

                	
                  3

                	
                  1

                	
                  45

                	
                  1

                	
                  2

                	
                  3

                	
                  1

                	
                  1

                	
                  2

                	
                  1

                	
                  1

                	
                  1

                	
                  1

                	
                  3

                	
                  2

                	
                  1

                	
                  5

                
	
                   

                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      South
West - Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Adams

                	
                  Brown

                	
                  Butler

                	
                  Clermont

                	
                  Clinton

                	
                  Hamilton

                	
                  Highland

                	
                  Warren

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  59

                	 
      	 
      	
                  7

                	
                  2

                	
                  1

                	
                  39

                	 
      	 
      	
                  10

                
	
                  OB/GYNs

                	
                  16

                	 
      	
                  1

                	
                  2

                	
                  1

                	
                  1

                	
                  9

                	 
      	
                  1

                	
                  1

                
	
                  Vision

                	
                  21

                	 
      	 
      	
                  3

                	
                  1

                	
                  1

                	
                  11

                	
                  1

                	
                  1

                	
                  3

                
	
                  General
      Surgeons

                	
                  13

                	 
      	 
      	
                  2

                	
                  1

                	
                  1

                	
                  7

                	 
      	
                  1

                	
                  1

                
	
                  Otolaryngologist

                	
                  6

                	 
      	 
      	
                  1

                	 
      	 
      	
                  3

                	 
      	
                  1

                	
                  1

                
	
                  Allergists

                	
                  7

                	 
      	 
      	 
      	 
      	 
      	
                  4

                	 
      	 
      	
                  3

                
	
                  Orthopedists

                	
                  9

                	 
      	 
      	
                  2

                	 
      	 
      	
                  5

                	 
      	 
      	
                  2

                
	
                  Dentists5

                	
                  50

                	
                  1

                	
                  1

                	
                  10

                	
                  4

                	
                  1

                	
                  26

                	
                  2

                	
                  2

                	
                  3

                
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      West
Central - Practitioners

       

       

      
        
          	
                  Minimum
      Provider Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Champaign

                	
                  Clark

                	
                  Darke

                	
                  Greene

                	
                  Miami

                	
                  Montgomery

                	
                  Preble

                	
                  Shelby

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  36

                	 
      	
                  2

                	 
      	
                  3

                	
                  1

                	
                  22

                	 
      	 
      	
                  8

                
	
                  OB/GYNs

                	
                  12

                	 
      	
                  2

                	 
      	
                  1

                	
                  1

                	
                  6

                	 
      	
                  1

                	
                  1

                
	
                  Vision

                	
                  20

                	 
      	
                  2

                	
                  1

                	
                  2

                	
                  2

                	
                  10

                	 
      	
                  1

                	
                  2

                
	
                  General
      Surgeons

                	
                  10

                	 
      	
                  2

                	 
      	
                  2

                	
                  1

                	
                  3

                	 
      	 
      	
                  2

                
	
                  Otolaryngologist

                	
                  7

                	 
      	
                  1

                	 
      	 
      	 
      	
                  3

                	 
      	 
      	
                  3

                
	
                  Allergists

                	
                  4

                	 
      	 
      	 
      	 
      	 
      	
                  2

                	 
      	 
      	
                  2

                
	
                  Orthopedists

                	
                  5

                	 
      	 
      	 
      	
                  1

                	 
      	
                  2

                	 
      	 
      	
                  2

                
	
                  Dentists5

                	
                  38

                	
                  1

                	
                  5

                	
                  1

                	
                  3

                	
                  3

                	
                  20

                	 
      	
                  1

                	
                  4

                
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
             

          

        

      

       

      North
West - Practitioners

       

       

      
        
          	
                   Minimum Provider
      Panel Requirements

                
	
                  Provider
      Types

                	
                  Total
      Required Providers1

                	
                  Allen

                	
                  Auglaize

                	
                  Defiance

                	
                  Fulton

                	
                  Hancock

                	
                  Hardin

                	
                  Henry

                	
                  Lucas

                	
                  Mercer

                	
                  Ottawa

                	
                  Paulding

                	
                  Putnam

                	
                  Sandusky

                	
                  Seneca

                	
                  Van
      Wert

                	
                  Williams

                	
                  Wood

                	
                  Wyandot

                	
                  Additional
      Required Providers2

                
	
                  Pediatricians4

                	
                  45

                	
                  4

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  23

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	
                  2

                	 
      	
                  13

                
	
                  OB/GYNs

                	
                  13

                	
                  2

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  5

                	 
      	 
      	 
      	 
      	
                  1

                	
                  1

                	 
      	 
      	
                  1

                	 
      	
                  2

                
	
                  Vision

                	
                  18

                	
                  2

                	
                  1

                	
                  1

                	 
      	
                  1

                	 
      	 
      	
                  7

                	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	
                  2

                	 
      	
                  1

                
	
                  General
      Surgeons

                	
                  13

                	
                  2

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  4

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  1

                	
                  2

                	 
      	
                  2

                
	
                  Otolaryngologist

                	
                  7

                	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  2

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  3

                
	
                  Allergists

                	
                  3

                	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                  1

                
	
                  Orthopedists

                	
                  7

                	
                  2

                	 
      	 
      	 
      	
                  1

                	 
      	 
      	
                  2

                	 
      	 
      	 
      	 
      	
                  1

                	 
      	 
      	 
      	
                  1

                	 
      	 
      
	
                  Dentists5

                	
                  45

                	
                  4

                	
                  1

                	
                  1

                	
                  1

                	
                  2

                	
                  1

                	
                  1

                	
                  20

                	
                  1

                	
                  1

                	 
      	
                  1

                	
                  2

                	
                  2

                	
                  1

                	
                  1

                	
                  2

                	
                  1

                	
                  2

                
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  1
      All required providers must be located within the region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  2
      Additional required providers may be located anywhere within the
      region.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  3
      Preferred Providers are the additional provider contracts that must be
      secured in order for the MCP to receive bonus points.

                	 
      	 
      	 
      	 
      	 
      	 
      
	
                  4
      Half of this number must be certified by the American Board of
      Pediatrics.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                  5 No
      more than two-thirds of this number can be pediatric
    dentists.

                	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


        

      

       

      
        
          
          

        

        
           

          
            

          

        

        
          
            Appendix
I

            Covered
Families and Children (CFC) population    


          

        

      

       

      APPENDIX
I

      


      PROGRAM
INTEGRITY

      CFC
ELIGIBLE POPULATION

      


      MCPs must
comply with all applicable program integrity requirements, including those
specified in 42 CFR 455 and 42 CFR 438 Subpart H.

      


      1.      
      Fraud and Abuse
Program:

      In
addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must
have a program that includes administrative and management arrangements or
procedures, including a mandatory compliance plan to guard against fraud and
abuse.  The MCP’s compliance plan must designate staff responsibility
for administering the plan and include clear goals, milestones or objectives,
measurements, key dates for achieving identified outcomes, and explain how the
MCP will determine the compliance plan’s effectiveness.

      


      In
addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance
program which safeguards against fraud and abuse must, at a minimum,
specifically address the following:

      


      
        	
                 
      

              	
                a.

              	
                Employee education
      about false claims recovery:  In order to comply with
      Section 6032 of the Deficit Reduction Act of 2005 MCPs must, as a
      condition of receiving Medicaid payment, do the
  following:

              


      

      


      
        	
                 
      

              	
                i.

              	
                establish
      and make readily available to all employees, including the MCP’s
      management, the following written policies regarding false claims
      recovery:

              


      

      


      
        	
                 
      

              	
                a.

              	
                detailed
      information about the federal False Claims Act and other state and federal
      laws related to the prevention and detection of fraud, waste, and abuse,
      including administrative remedies for false claims and statements as well
      as civil or criminal penalties;

              


      

      


      
        	
                 
      

              	
                b.

              	
                the
      MCP’s policies and procedures for detecting and preventing fraud, waste,
      and abuse; and

              


      

      


      
        	
                 
      

              	
                c.

              	
                the
      laws governing the rights of employees to be protected as
      whistleblowers.

              


      

      


      
        	
                 
      

              	
                ii.

              	
                include
      in any employee handbook the required written policies regarding false
      claims recovery;

              


      

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
I

            Covered
Families and Children (CFC) population    


          

        

      

       

      
        	
                 
      

              	
                iii.

              	
                establish
      written policies for any MCP contractors and agents that provide detailed
      information about the federal False Claims Act and other state and federal
      laws related to the prevention and detection of fraud, waste, and abuse,
      including administrative remedies for false claims and statements as well
      as civil or criminal penalties,; the laws
      governing the rights of employees to be protected as whistleblowers; and
      the MCP’s policies and procedures for detecting and preventing fraud,
      waste, and abuse.  MCPs must make such information readily
      available to their subcontractors;
and

              


      

       

      
        	
                 
      

              	
                iv.

              	
                disseminate
      the required written policies to all contractors and agents, who must
      abide by those written policies.

              


      

       

      
        	
                 
      

              	
                b.

              	
                Monitoring for fraud
      and abuse The MCP’s program which safeguards against fraud and
      abuse must specifically address the MCP’s prevention, detection,
      investigation, and reporting strategies in at least the following
      areas:

              


      

      


      
        	
                 
      

              	
                i.

              	
                Embezzlement
      and theft – MCPs must monitor activities on an ongoing basis to prevent
      and detect activities involving embezzlement and theft (e.g., by staff,
      providers, contractors, etc.) and respond promptly to such
      violations.

              


      

      


      
        	
                 
      

              	
                ii.

              	
                Underutilization
      of services – MCPs must monitor for the potential underutilization of
      services by their members in order to assure that all Medicaid-covered
      services are being provided, as required.  If any underutilized
      services are identified, the MCP must immediately investigate and, if
      indicated, correct the problem(s) which resulted in such underutilization
      of services.

              


      

      


        
The MCP’s monitoring efforts must, at a minimum, include the following
activities:  a) an annual review of their prior authorization
procedures to determine that  

        
they do not unreasonably limit a member’s access to Medicaid-covered services;
b) an annual review of the procedures providers are to follow in appealing
the

       
 MCP’s denial of a prior authorization request to determine that the
process does not unreasonably limit a member’s access to Medicaid-covered
services; and c)

       
 ongoing monitoring of MCP service denials and utilization in order to
identify services which may be underutilized.

      


      
        	
                 
      

              	
                iii.

              	
                Claims
      submission and billing – On an ongoing basis, MCPs must identify and
      correct claims submission and billing activities which are potentially
      fraudulent including, at a minimum, double-billing and improper coding,
      such as upcoding and bundling.

              


      

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
I

            Covered
Families and Children (CFC) population    


          

        

      

       

      
        	
                 
      

              	
                c.

              	
                Reporting MCP fraud
      and abuse activities:  Pursuant to OAC rule 5101:3-26-06,
      MCPs are required to submit annually to ODJFS a report which summarizes
      the MCP’s fraud and abuse activities for the previous year in each of the
      areas specified above.  The MCP’s report must also identify any
      proposed changes to the MCP’s compliance plan for the coming
      year.

              


      

       

      
        	
                 
      

              	
                d.

              	
                Reporting
      fraud and abuse:  MCPs are required to promptly report all
      instances of provider fraud and abuse to ODJFS and member fraud to the
      CDJFS.  The MCP, at a minimum, must
      report the following information on cases where the
      MCP’s  investigation has revealed that an incident of fraud
      and/or abuse has occurred:

              	
                 

              


      

      


      
        	
                 
      

              	
                i.

              	
                provider’s
      name and Medicaid provider number or provider reporting number
      (PRN);

              


      

      


      ii.           source
of complaint;

      


      iii.           type
of provider;

      


      iv.           nature
of complaint;

      


      v.           approximate
range of dollars involved, if applicable;

      


      vi.           results
of MCP’s investigation and actions taken;

      


      vii.           name(s)
of other agencies/entities (e.g., medical board, law enforcement)notified by
MCP; and

      


      
        	
                 
      

              	
                viii.

              	
                legal
      and administrative disposition of case, including actions taken by law
      enforcement officials to whom the case has been
  referred.

              


      

       

      
        	
                 
      

              	
                e.

              	
                Monitoring for
      prohibited affiliations:  The MCP’s policies and
      procedures for ensuring that, pursuant to 42 CFR 438.610, the MCP will not
      knowingly have a relationship with individuals debarred by Federal
      Agencies, as specified in Article XII of the
  Agreement.

              


      

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
I

            Covered
Families and Children (CFC) population    


          

        

      

      
2.           Data
Certification:

      Pursuant
to 42 CFR 438.604 and 42 CFR 438.606, MCPs are required to provide certification
as to the accuracy, completeness, and truthfulness of data and documents
submitted to ODJFS which may affect MCP payment.

      


      
        	
                 
      

              	
                a.

              	
                MCP
      Submissions:  MCPs must submit the appropriate
      ODJFS-developed certification concurrently with the submission of the
      following data or documents:

              


      

      


      i.            
Encounter Data [as specified in the Data Quality Appendix (Appendix
L)]

      


      
        	
                 
      

              	
                ii.

              	
                Prompt
      Pay Reports [as specified in the Fiscal Performance Appendix (Appendix
      J)]

              


      

      


      
        	
                 
      

              	
                iii.

              	
                Cost
      Reports [as specified in the Fiscal Performance Appendix (Appendix
      J)]

              


      

       

                     
       
iv.           Case
Management Data [as specified in the Data Quality Appendix

                            
(Appendix L)]

      
         

      

      
        	
                 
      

              	
                b.

              	
                Source of
      Certification:  The above MCP data submissions must be
      certified by one of the following:

              


      

      


      i.          
  The MCP’s Chief Executive Officer;

      


      ii.            The
MCP’s Chief Financial Officer, or

      


      
        	
                 
      

              	
                iii.

              	
                An
      individual who has delegated authority to sign for, or who reports
      directly to, the MCP’s Chief Executive Officer or Chief Financial
      Officer.

              


      

      


            
ODJFS may also require MCPs to certify as to the accuracy, completeness, and
truthfulness of additional submissions.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
J

            Covered
Families and Children (CFC)
population 

          

        

      

       

      WellCare

      


      APPENDIX
J

      


      FINANCIAL
PERFORMANCE

      CFC
ELIGIBLE POPULATION

      


      1.           
SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS

      


      MCPs must submit the following
financial reports to ODJFS:

      


      
        	
                 
      

              	
                a.

              	
                The
      National Association of Insurance Commissioners (NAIC) quarterly and
      annual Health Statements (hereafter referred to as the “Financial
      Statements”), as outlined in Ohio Administrative Code (OAC) rule
      5101:3-26-09(B).  The Financial Statements must include all
      required Health Statement filings, schedules and exhibits as stated in the
      NAIC Annual Health Statement Instructions including, but not limited to,
      the following sections:  Assets, Liabilities, Capital and
      Surplus Account, Cash Flow, Analysis of Operations by Lines of Business,
      Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and
      Utilization.  The Financial Statements must be submitted to BMHC
      even if the Ohio Department of Insurance (ODI) does not require the MCP to
      submit these statements to ODI.  A signed hard copy and an
      electronic copy of the reports in the NAIC-approved format must both be
      provided to ODJFS;

              


      

      


      
        	
                 
      

              	
                b.

              	
                Hard
      copies of annual financial statements for those entities who have an
      ownership interest totaling five percent or more in the MCP or an indirect
      interest of five percent or more, or a combination of direct and indirect
      interest equal to five percent or more in the
  MCP;

              


      

      


      
        	
                 
      

              	
                c.

              	
                Annual
      audited Financial Statements prepared by a licensed independent external
      auditor as submitted to the ODI, as outlined in OAC rule
      5101:3-26-09(B);

              


      

      


      
        	
                 
      

              	
                d.

              	
                Medicaid
      Managed Care Plan Annual Ohio Department of Job and Family Services
      (ODJFS) Cost Report and the auditor’s certification of the cost report, as
      outlined in OAC rule
5101:3-26-09(B);

              


      

      


      
        	
                 
      

              	
                e.

              	
                Medicaid
      MCP Annual Restated Cost Report for the prior calendar
      year.  The restated cost report shall be audited upon BMHC
      request;

              


      

       

      
        	
                 
      

              	
                f.

              	
                Annual
      physician incentive plan disclosure statements and disclosure of and
      changes to the MCP’s physician incentive plans, as outlined in OAC rule
      5101:3-26-09(B);

              


      

       

                      g.          
 Reinsurance agreements, as outlined in OAC rule
5101:3-26-09(C);

      


      
        	
                 
      

              	
                h.

              	
                Prompt
      Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an
      electronic copy of the reports in the ODJFS-specified format must be
      provided to ODJFS;

              


      

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
J

            Covered
Families and Children (CFC)
population 

          

        

      

       

      
        	
                 
      

              	
                i.

              	
                Notification
      of requests for information and copies of information released pursuant to
      a tort action (i.e., third party recovery), as outlined in OAC rule
      5101:3-26-09.1;

              


      

      


      
        	
                 
      

              	
                j.

              	
                Financial,
      utilization, and statistical reports, when ODJFS requests such reports,
      based on a concern regarding the MCP’s quality of care, delivery of
      services, fiscal operations or solvency, in accordance with OAC rule
      5101:3-26-06(D);

              


      

      


      
        	
                 
      

              	
                k.

              	
                In
      accordance with ORC Section 5111.76 and Appendix C, MCP Responsibilities,
      MCPs must submit ODJFS-specified franchise fee reports in hard copy and
      electronic formats pursuant to ODJFS
  specifications.

              


      

       

      2.         
  FINANCIAL PERFORMANCE MEASURES AND STANDARDS

      


      This
Appendix establishes specific expectations concerning the financial performance
of MCPs.  In the interest of administrative simplicity  and
nonduplication of areas of the ODI authority, ODJFS’  emphasis is on
the assurance of access to and quality of care. ODJFS will focus only on a
limited number of indicators and related standards to monitor plan
performance.  The three indicators and standards for this contract
period are identified below, along with the calculation
methodologies.  The source for each indicator will be the NAIC
Quarterly and Annual Financial Statements.

      


      Report Period: Compliance
will be determined based on the annual Financial

      Statement.

      


      a.         
   Indicator:               Net Worth as measured by Net Worth
Per Member

      


      
        	
                 
      

              	
                Definition:

              	
                Net
      Worth = Total Admitted Assets minus Total Liabilities divided by Total
      Members across all lines of
business

              


      

      


      
        	
                 
      

              	
                Standard:

              	
                For
      the financial report that covers calendar year 2008, a minimum net worth
      per member of $363.00, as determined from the annual Financial Statement
      submitted to ODI and the ODJFS.

              


      

      


      The Net
Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount
paid to the MCP during the preceding calendar year, including delivery payments,
but excluding the at-risk amount, expressed as a per-member per-month figure,
multiplied by the applicable proportion below:

      


      0.75 if
the MCP had a total membership of 100,000 or more during that calendar year 0.90
if the MCP had a total membership of less than 100,000 for that calendar
year.  If the MCP did not receive Medicaid Managed Care Capitation
payments during the preceding calendar year, then the NWPM standard for the MCP
is the average Medicaid Managed Care capitation amount paid to
Medicaid-contracting MCPs during the preceding calendar year, including delivery
payments, but excluding the at-risk amount, multiplied by the applicable
proportion above.

      


      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
J

            Covered
Families and Children (CFC)
population 

          

        

      

                

            
b.           Indicator:               Administrative Expense
Ratio

      


      
        	
                 
      

              	
                Definition:

              	
                Administrative
      Expense Ratio = Administrative Expenses minus Franchise Fees divided by
      Total Revenue minus Franchise Fees.

              


      

      


      
        	
                 
      

              	
                Standard:

              	
                Administrative
      Expense Ratio not to exceed 15%, as determined from the annual Financial
      Statement submitted to ODI and
ODJFS.

              


      

       

      
        c.          
  Indicator:              Overall Expense
Ratio

        


        Definition:            Overall
Expense Ratio = The sum of the Administrative Expense Ratio and the Medical
Expense Ratio. 

         

        Administrative
Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total
Revenue minus Franchise Fees.

        


        Medical
Expense Ratio = Medical Expenses divided by Total Revenue minus Franchise
Fees.

        


        
          	
                   
      

                	
                  Standard:

                	
                  Overall
      Expense Ratio not to exceed 100% as determined from the annual Financial
      Statement submitted to ODI and
ODJFS.

                


        

      

       

      Penalty for noncompliance:
Failure to meet any standard on 2.a., 2.b., or 2.c. above will result in ODJFS
requiring the MCP to complete a corrective action plan (CAP) and specifying the
date by which compliance must be demonstrated.  Failure to meet the
standard or otherwise comply with the CAP by the specified date will result in a
new membership freeze unless ODJFS determines that the deficiency does not
potentially jeopardize access to or quality of care or affect the MCP’s ability
to meet administrative requirements (e.g., prompt pay
requirements).  Justifiable reasons for noncompliance may include
one-time events (e.g., MCP investment in information system
products).

      


      If the
financial statement is not submitted to ODI by the due date, the MCP continues
to be obligated to submit the report to ODJFS by ODI’s originally specified due
date unless the MCP requests and is granted an extension by ODJFS.

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
J

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Failure
to submit complete quarterly and annual Financial Statements on a timely basis
will be deemed a failure to meet the standards and will be subject to the
noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including
the imposition of a new membership freeze.  The new membership freeze
will take effect at the first of the month following the month in which the
determination was made that the MCP was non-compliant for failing to submit
financial reports timely.

      


      In
addition, ODJFS will review two liquidity indicators if a plan demonstrates
potential problems in meeting related administrative requirements or the
standards listed above.  The two standards, 2.d and 2.e, reflect
ODJFS’ expected level of performance.  At this time, ODJFS has not
established penalties for noncompliance with these standards; however, ODJFS
will consider the MCP’s performance regarding the liquidity measures, in
addition to indicators 2.a., 2.b., and 2.c., in determining whether to impose a
new membership freeze, as outlined above, or to not issue or renew a contract
with an MCP.  The source for each indicator will be the NAIC Quarterly
and annual Financial Statements.

      


      Long-term
investments that can be liquidated without significant penalty within 24 hours,
which a plan would like to include in Cash and Short-Term Investments in the
next two measurements, must be disclosed in footnotes on the NAIC
Reports.  Descriptions and amounts should be
disclosed.  Please note that “significant penalty” for this purpose is
any penalty greater than 20%. Also, enter the amortized cost of the investment,
the market value of the investment, and the amount of the penalty.

      


      d.       
    Indicator:          
    Days
Cash on Hand

      


      
        	
                 
      

              	
                Definition:

              	
                Days
      Cash on Hand = Cash and Short-Term Investments divided by (Total Hospital
      and Medical Expenses plus Total Administrative Expenses) divided by
      365.

              


      

      


      
        	
                 
      

              	
                Standard:

              	
                Greater
      than 25 days as determined from the annual Financial Statement submitted
      to ODI and ODJFS.

              


      

      


      e.          
  Indicator:              Ratio of Cash to Claims
Payable

      


      
        	
                 
      

              	
                Definition:

              	
                Ratio
      of Cash to Claims Payable = Cash and Short-Term Investments divided by
      claims Payable (reported and
unreported).

              


      

      


      
        	
                 
      

              	
                Standard:

              	
                Greater
      than 0.83 as determined from the annual Financial Statement submitted to
      ODI and ODJFS.

              


      

       

      
        
          
             


          

          
            4

            
              

            

          

          
            
              Appendix
J

              Covered
Families and Children (CFC) population 


            

          

        

      

      


      3.          
 REINSURANCE REQUIREMENTS

      


      Pursuant
to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry reinsurance
coverage from a licensed commercial carrier to protect against inpatient-related
medical expenses incurred by Medicaid members.

      


      The
annual deductible or retention amount for such insurance must be specified in
the reinsurance agreement and must not exceed $75,000.00, except as provided
below.  Except for transplant services, and as provided below, this
reinsurance must cover, at a minimum, 80% of inpatient costs incurred by one
member in one year, in excess of $75,000.00.

      


      For
transplant services, the reinsurance must cover, at a minimum, 50% of inpatient
transplant related costs incurred by one member in one year, in excess of
$75,000.00.

      


      An MCP
may request a higher deductible amount and/or that the reinsurance cover less
than 80% of inpatient costs in excess of the deductible amount.  If
the MCP does not have more than 75,000 members in Ohio, but does have more than
75,000 members between Ohio and other states, ODJFS may consider alternate
reinsurance arrangements.  However, depending on the corporate
structures of the Medicaid MCP, other forms of security may be required in
addition to reinsurance.  These other security tools may include
parental guarantees, letters of credit, or performance bonds. In determining
whether or not the request will be approved, the ODJFS may consider any or all
of the following:

      


      
        	
                 
      

              	
                a.

              	
                whether
      the MCP has sufficient reserves available to pay unexpected
      claims;

              


      

      


      
        	
                 
      

              	
                b.

              	
                the
      MCP’s history in complying with financial indicators 2.a., 2.b., and 2.c.,
      as specified in this Appendix.

              


      

       

          c.    
       the number of members covered by the
MCP;

      


      
        	
                 
      

              	
                d.

              	
                how
      long the MCP has been covering Medicaid or other members on a full risk
      basis.

              


      

       

          e.        
    risk based capital ratio greater than 2.5 calculated
from the last annual ODI financial statement.

      


      
        	
                 
      

              	
                f.

              	
                scatter
      diagram or bar graph from the last calendar year that shows the number of
      reinsurance claims that exceeded the current reinsurance
      deductible.

              


      

       

          The MCP has been
approved  to have a reinsurance policy with a deductible amount
of  $75,000 that covers 80% of inpatient costs in excess of the
deductible amount  

                      for
non- transplant services.

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
J

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Penalty for noncompliance: If
it is determined that an MCP failed to have reinsurance coverage, that an MCP’s
deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP’s
reinsurance for non-transplant services covers less than 80% of inpatient costs
in excess of the deductible incurred by one member for one year without approval
from ODJFS, then the MCP will be required to pay a monetary penalty to
ODJFS.  The amount of the penalty will be the difference between the
estimated amount, as determined by ODJFS, of what the MCP would have paid in
premiums for the reinsurance policy if it had been in compliance and what the
MCP did actually pay while it was out of compliance plus 5%.  For
example, if the MCP paid $3,000,000.00 in premiums during the period of
non-compliance and would have paid $5,000,000.00 if the requirements had been
met, then the penalty would be $2,100,000.00.

      


      If it is
determined that an MCP’s reinsurance for transplant services covers less than
50% of inpatient costs incurred by one member for one year, the MCP will be
required to develop a corrective action plan (CAP).

       

      
        	
                 4.   

              	
                
                  PROMPT
      PAY REQUIREMENTS

                

              	
                 

              


      

      


      In
accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
within 30 days of the date of receipt and 99% of such claims within 90 days of
the date of receipt, unless the MCP and its contracted provider(s) have
established an alternative payment schedule that is mutually agreed upon and
described in their contract.  The clean pharmacy and non-pharmacy
claims will be separately measured against the 30 and 90 day prompt pay
standards.  The prompt pay requirement applies to the processing of
both electronic and paper claims for contracting and non-contracting providers
by the MCP and delegated claims processing entities.

      


      The date
of receipt is the date the MCP receives the claim, as indicated by its date
stamp on the claim.  The date of payment is the date of the check or
date of electronic payment transmission.  A claim means a bill from a
provider for health care services that is assigned a unique
identifier.  A claim does not include an encounter form.

      


      A “claim”
can include any of the following:  (1) a bill for services; (2) a line
item of services; or (3) all services for one recipient within a
bill.  A “clean claim” is a claim that can be processed without
obtaining additional information from the provider of a service or from a third
party.

      


      Clean
claims do not include payments made to a provider of service or a third party
where the timing of the payment is not directly related to submission of a
completed claim by the provider of service or third party (e.g.,
capitation).  A clean claim also does not include a claim from a
provider who is under investigation for fraud or abuse, or a claim under review
for medical necessity.

      


      Penalty for
noncompliance:  Noncompliance with prompt pay requirements will
result in progressive penalties to be assessed on a quarterly basis, as outlined
in Appendix N of the Provider Agreement.

      


      
        
          
             


          

          
            6

            
              

            

          

          
            
              Appendix
J

              Covered
Families and Children (CFC) population 


            

          

        

      

       

      5.          
 PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS

      


      MCPs must
comply with the physician incentive plan requirements stipulated in 42 CFR
438.6(h).  If
the MCP operates a physician incentive plan, no specific payment can be made
directly or indirectly under this physician incentive plan to a physician or
physician group as an inducement to reduce or limit medically necessary services
furnished to an individual.

      


      If the
physician incentive plan places a physician or physician group at substantial
financial risk [as determined under paragraph (d) of 42 CFR 422.208] for
services that the physician or physician group does not furnish itself, the MCP
must assure that all physicians and physician groups at substantial financial
risk have either aggregate or per-patient stop-loss protection in accordance
with paragraph (f) of 42 CFR 422.208, and conduct periodic surveys in accordance
with paragraph (h) of 42 CFR 422.208.

      


      In
accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies of
the following required documentation and submit to upon request:

      


      
        	
                 
      

              	
                a.

              	
                A
      description of the types of physician incentive arrangements the MCP has
      in place which indicates whether they
      involve a withhold, bonus, capitation, or other arrangement.  If
      a physician incentive arrangement involves a withhold or bonus, the
      percent of the withhold or bonus must be
  specified.

              


      

      


      
        	
                 
      

              	
                b.

              	
                A
      description of information/data feedback to a physician/group on their: 1)
      adherence to evidence-based practice guidelines; and  2)
      positive and/or negative care variances from standard clinical pathways
      that may impact outcomes or costs.  The feedback information may
      be used by the MCP for activities such as physician performance
      improvement projects that include incentive programs or the development of
      quality improvement initiatives.

              


      

      


      
        	
                 
      

              	
                c.

              	
                A
      description of the panel size for each physician incentive
      plan.  If patients are pooled, then the pooling method used to
      determine if substantial financial risk exists must also be
      specified.

              


      

      


      
        	
                 
      

              	
                d.

              	
                If
      more than 25% of the total potential payment of a physician/group is at
      risk for referral services, the MCP must maintain a copy of the results of
      the required
      patient satisfaction survey and documentation verifying that the physician
      or physician group has adequate stop-loss protection, including the type
      of coverage (e.g., per member per year, aggregate), the threshold amounts,
      and any coinsurance required for amounts over the
    threshold.

              


      

       

      
        6.           NOTIFICATION
OF REGULATORY ACTION

        


        Any MCP
notified by the ODI of proposed or implemented regulatory action must report
such notification and the nature of the action to ODJFS no later than one
working day after receipt from ODI.  The ODJFS may request, and the
MCP must provide, any additional information as necessary to assure continued
satisfaction of program requirements.  MCPs may request that
information related to such actions be considered proprietary in accordance with
established ODJFS procedures.  Failure to comply with this provision
will result in an immediate membership freeze.

      

       

      
        
          
             


          

          
            7

            
              

            

          

          
            
              Appendix
K

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      APPENDIX
K

      
         

      

      QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

      AND

      EXTERNAL
QUALITY REVIEW

      CFC
ELIGIBLE POPULATION

      


      1.         
   As required by federal regulation, 42 CFR 438.240, each
managed care plan (MCP) must have an ongoing Quality Assessment and Performance
Improvement Program (QAPI) 

                     
that is annually prior-approved by the Ohio Department of Job and Family
Services (ODJFS).  The program must include the following
elements:

      


      a.           PERFORMANCE IMPROVEMENT
PROJECTS

      


      Each MCP
must conduct performance improvement projects (PIPs), including those specified
by ODJFS.  PIPs must achieve, through periodic measurements and
intervention, significant and sustained improvement in clinical and non-clinical
areas which are expected to have a favorable effect on health outcomes and
satisfaction.  MCPs must adhere to ODJFS PIP content and format
specifications.

      


      All
ODJFS-specified PIPs must be prior-approved by ODJFS.  As part of the
external quality review organization (EQRO) process, the EQRO will assist MCPs
with conducting PIPs by providing technical assistance and will annually
validate the PIPs.  In addition, the MCP must annually submit to ODJFS
the status and results of each PIP.

      


      MCPs must
initiate the following PIPs:

      


      
        	
                 
      

              	
                i.

              	
                Non-clinical
      Topic:  Identifying children/members with special health
      care needs.

              


      

      


      ii.           Clinical
Topic:  Well-child visits during the first 15 months of
life.

      


      iii.         
Clinical
Topic:  Percentage of members aged 2-21 years that access
dental care   services.

      


      Initiation
of PIPs will begin in the second year of participation in the Medicaid managed
care program.

       

      b.           UNDER- AND
OVER-UTILIZATION

      


      Each MCP
must have mechanisms in place to detect under- and over-utilization of health
care services.  The MCP must specify the mechanisms used to monitor
utilization in its annual submission of the QAPI program to ODJFS.

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
K

            Covered
Families and Children (CFC)
population   

          

        

      

       

      It should
also be noted that pursuant to the program integrity provisions outlined in
Appendix I, MCPs must monitor for the potential under-utilization of services by
their members in order to assure that all Medicaid-covered services are being
provided, as required.  If any under-utilized services are identified,
the MCP must immediately investigate and correct the problem(s) which resulted
in such under-utilization of services.

       

      In
addition the MCP must conduct an ongoing review of service denials and must
monitor utilization on an ongoing basis in order to identify services which may
be under-utilized.

      


      c.           SPECIAL HEALTH CARE
NEEDS

      


      Each MCP
must have mechanisms in place to assess the quality and appropriateness of care
furnished to children/members with special health care needs.  The MCP
must specify the mechanisms used in its annual submission of the QAPI program to
ODJFS.

       

      d.           SUBMISSION OF PERFORMANCE
MEASUREMENT DATA

      


      Each MCP
must submit clinical performance measurement data as required by ODJFS that
enables ODJFS to calculate standard measures.  Refer to Appendix M
“Performance Evaluation” for a more comprehensive description of the clinical
performance measures.

      


      Each MCP
must also submit clinical performance measurement data as required by ODJFS that
uses standard measures as specified by ODJFS.  MCPs are required to
submit Health Employer Data Information Set (HEDIS) audited data for the
following measures:

      


      
        	
                 
      

              	
                i.

              	
                Well
      Child Visits in the First 15 Months of
Life

              

                             
ii.            
  Child Immunization Status

       

      
        The
measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population.  Data must be
submitted annually and in an electronic format.  Data will be used for
MCP clinical performance monitoring and will be incorporated into comparative
reports developed by the EQRO.

        


        Initiation
of submission of performance data will begin in the second year of participation
in the Medicaid managed care program.

         

        e.           QAPI PROGRAM
SUBMISSION

        
          


          Each MCP must implement an evaluation
process to review, revise, and/or update the

          QAPI
program.  The MCP must annually submit its QAPI program for review and
approval by ODJFS.

        

         

        
          
            
            

          

          
            2

            
              

            

          

          
            
              Appendix
K

              Covered
Families and Children (CFC)
population   

            

          

        

         

      

      2.   
        EXTERNAL QUALITY
REVIEW

      


      In
addition to the following requirements, MCPs must participate in external
quality review activities as outlined in OAC 5101:3-26-07.

       

      a.           EQRO ADMINISTRATIVE
REVIEWS

      


      The EQRO
will conduct annual focused administrative compliance assessments for each MCP
which will include, but not be limited to, the following domains as specified by
ODJFS:  member rights and services, QAPI program, case management,
provider networks, grievance system, coordination and continuity of care, and
utilization management.  In addition, the EQRO will complete a
comprehensive administrative compliance assessment every three (3) years as
required by 42 CFR 438.358 and specified by ODJFS.

      


      In
accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation
from a national accrediting organization approved by the Centers for Medicare
and Medicaid Services (CMS) may request a non-duplication exemption from certain
specified components of the administrative review.  ODJFS will inform
the MCPs when a non-duplication exemption may be requested.

      


      b.           EXTERNAL QUALITY REVIEW
PERFORMANCE

      


      In
accordance with OAC 5101:  3-26-07, each MCP must participate in
an annual external quality review survey.  If the EQRO cites a
deficiency in performance, the MCP will be required to complete a Corrective
Action Plan (e.g., ODJFS technical assistance session) or Quality Improvement
Directives depending on the severity of the deficiency.  (An example
of a deficiency is if an MCP fails to meet certain clinical or administrative
standards as supported by national evidence-based guidelines or best
practices.)  Serious  deficiencies may result in immediate
termination or non-renewal of the provider agreement.  These quality
improvement measures recognize the importance of ongoing MCP performance
improvement related to clinical care and service delivery.

       

      
        
          
             


          

          
            3

            
              

            

          

          
            
              Appendix
L

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      APPENDIX
L

      


      DATA
QUALITY

      CFC
ELIGIBLE POPULATION

      


      A high
level of performance on the data quality measures established in this appendix
is crucial in order for the Ohio Department of Job and Family Services (ODJFS)
to determine the value of the Medicaid Managed Health Care Program and to
evaluate Medicaid consumers’ access to and quality of services. Data collected
from MCPs are used in key performance assessments such as the external quality
review, clinical performance measures, utilization review, care coordination and
case management, and in determining incentives.  The data will also be
used in conjunction with the cost reports in setting the premium payment
rates.  The following measures, as specified in this appendix, will be
calculated per MCP and include all Ohio Medicaid members receiving services from
the MCP (i.e., Covered Families and Children (CFC) and Aged, Blind, or Disabled
(ABD) membership, if applicable):  Incomplete Outpatient Hospital
Data, Rejected Encounters, Acceptance Rate, Encounter Data Accuracy, and Generic
Provider Number Usage. 

      


      Data sets
collected from MCPs with data quality standards include: encounter data; case
management data; data used in the external quality review; members’ PCP data;
and appeal and grievance data.

      


      1.          
   ENCOUNTER DATA

      


      For
detailed descriptions of the encounter data quality measures below, see ODJFS Methods for Encounter Data
Quality Measures for CFC and ABD.

      


      1.a.           Encounter
Data Completeness

      


      Each
MCP’s encounter data submissions will be assessed for
completeness.  The MCP is responsible for collecting information from
providers and reporting the data to ODJFS in accordance with program
requirements established in Appendix C, MCP
Responsibilities.  Failure to do so jeopardizes the MCP’s
ability to demonstrate compliance with other performance standards.

      


      1.a.i.         Encounter
Data Volume

      


      Measure:  The
volume measure for each service category, as listed in Table 2 below, is the
rate of utilization (e.g., discharges, visits) per 1,000 member months
(MM).

      


      Report Period:  The
report periods for the SFY 2009 and SFY 2010 contract periods are listed in
Table 1. below.

       

      
        
          
             


          

          
            1

            
              

            

          

          
            
              Appendix
L

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      Table
1. Report Periods for the SFY 2009 and 2010 Contract Periods

      
        
          	
                  Quarterly
      Report Periods

                	
                  Data
      Source:

                  Estimated
      Encounter  Data File Update

                	
                  Quarterly
      Report

                  Estimated
      Issue Date

                	
                  Contract
      Period

                
	
                   

                  Qtr
      2 thru Qtr 4 2005,

                  Qtr
      1 thru Qtr 4: 2006, 2007

                  Qtr
      1 2008

                	
                  July
      2008

                	
                  August
      2008

                	
                  SFY
      2009

                
	
                  Qtr
      3, Qtr 4: 2005,

                  Qtr
      1 thru Qtr 4: 2006, 2007

                  Qtr
      1, Qtr 2 2008

                	
                  October  2008

                	
                  November  2008

                
	
                  Qtr
      4: 2005,

                  Qtr
      1 thru Qtr 4: 2006, 2007

                  Qtr
      1 thru Qtr 3: 2008

                	
                  January  2009

                	
                  February  2009

                
	
                  Qtr
      1 thru Qtr 4: 2006, 2007, 2008

                	
                  April  2009

                	
                  May  2009

                
	
                  Qtr
      2 thru Qtr 4: 2006,

                  Qtr
      1 thru Qtr 4: 2007, 2008

                  Qtr
      1 2009

                	
                  July
      2009

                	
                  August
      2009

                	
                  SFY
      2010

                
	
                  Qtr
      3, Qtr 4: 2006,

                  Qtr
      1 thru Qtr 4: 2007, 2008

                  Qtr
      1, Qtr 2: 2009

                	
                  October
      2009

                	
                  November
      2009

                
	
                  Qtr
      4: 2006,

                  Qtr
      1 thru Qtr 4: 2007, 2008

                  Qtr
      1 thru Qtr 3: 2009

                	
                  January
      2010

                	
                  February
      2010

                
	
                  Qtr
      1 thru Qtr 4: 2007, 2008, 2009

                	
                  April
      2010

                	
                  May
      2010

                


        
Qtr1 =
January to
March                                                        
Qtr2 = April to
June                                              Qtr3
= July to SeptemberQtr4 = October to December

       

      
        
          
             


          

          
            2

            
              

            

          

          
            
              Appendix
L

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      Table
2. Standards – Encounter Data Volume (County-Based Approach)

      


      Data Quality Standard, County-Based
Approach:  The standards in Table 2 apply to the MCP’s
county-based results (see County-Based Approach
below).  The utilization rate for all service categories listed in
Table 2 must be equal to or greater than the standard established in Table 2
below.

      


      
        	
                Category

              	
                Measure
      per 1,000/MM

              	
                Standard
      for Dates of Service

                7/1/2003
      thru 6/30/2004

              	
                Standard
      for Dates of Service

                7/1/2004
      thru 6/30/2006

              	
                Standard
      for Dates of Service

                on
      or after 7/1/2006

              	
                Description

              
	
                Inpatient
      Hospital

              	
                Discharges

              	
                5.4

              	
                5.0

              	
                5.4

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                Visits

              	
                51.6

              	
                51.4

              	
                50.7

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                38.2

              	
                41.7

              	
                50.9

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                11.6

              	
                11.6

              	
                10.6

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      and Specialist Care

              	
                220.1

              	
                225.7

              	
                233.2

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                144.7

              	
                123.0

              	
                133.6

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                7.6

              	
                8.6

              	
                10.5

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                388.5

              	
                457.6

              	
                492.2

              	
                Prescribed
      drugs

              


      

       

      County-Based
Approach:  All counties with managed care membership as
of  February 1, 2006, will be included in a county-based encounter
data volume measure until regional evaluation is implemented for the county’s
applicable region..  Upon implementation of  regional-based
evaluation for a particular county’s region, the county will be included in the
MCP’s regional-based results and will no longer be included in the MCP’s
county-based results. County-based results
will be determined by MCP (i.e., one utilization rate per service category for
all applicable counties) and must be equal to or greater than the standards
established in Table 2 above.  [Example: The county-based result for
MCP AAA, which has contracts in the Central and West Central regions, will
include Franklin, Pickaway, Montgomery, Greene and Clark counties (i.e.,
counties with managed care membership as of February 1, 2006).  When
the regional-based evaluation is implemented for the Central region, Franklin
and Pickaway counties, along with all other counties in the region, will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and
Clark counties will remain in the county-based results for MCP AAA until the
West Central regional measure is implemented.]

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Interim
Regional-Based Approach:

      Prior to
the transition to the regional-based approach, encounter data volume will be
evaluated by MCP, by region, using an interim approach.  All regions
with managed care membership will be included in results for an interim
regional-based encounter data volume measure until regional evaluation is
implemented for the applicable region (see Regional-Based Approach
below).  Encounter data volume will be evaluated by MCP ( i.e., one
utilization rate per service category for all counties in the
region).  The utilization rate for all service categories listed in
Table 3 must be equal to or greater than the standard established in Table 3
below.  The standards listed in Table 3 below are based on utilization
data for counties with managed care membership as of February 1, 2006, and have
been adjusted to accommodate estimated differences in utilization for all
counties in a region, including counties that did not have membership as of
February 1, 2006.

      


      Prior to
implementation of the regional-based approach, an MCP’s encounter data volume
will be evaluated using the county-based approach and the interim regional-based
approach.  A county with managed care membership as of February 1,
2006, will be included in both the County-Based approach and the Interim
Regional-Based approach until regional evaluation is implemented for the
county’s applicable region.

      


      Data Quality Standard, Interim
Regional-Based Approach:  The standards in Table 3 apply to the
MCP’s interim regional-based results.  The utilization rate for all
service categories listed in Table 3 must be equal to or greater than the
standard established in Table 3 below.

       

      Table
3.                      Standards
– Encounter Data Volume (Interim Regional-Based Approach)

      


      
        	
                Category

              	
                Measure
      per 1,000/MM

              	
                Standard
      for Dates of Service

                on
      or after 7/1/2006

              	
                Description

              
	
                Inpatient
      Hospital

              	
                Discharges

              	
                2.7

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                Visits

              	
                25.3

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                25.5

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                5.3

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      and Specialist Care

              	
                116.6

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                66.8

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                5.2

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                246.1

              	
                Prescribed
      drugs

              


      

       

      Regional-Based
Approach:

      Transition
to the regional-based approach will occur by region, after the first four
quarters (i.e., full calendar year quarters) of regional
membership.  Encounter data volume will be evaluated by MCP, by region
(i.e., one utilization rate per service category for all counties in the
region), after determination of the regional-based data quality
standards.  ODJFS will use the first four quarters of data (i.e., full
calendar year quarters) from all MCPs serving in an active region to determine
minimum encounter volume data quality standards for that region.

      


      The
utilization rate for all service categories listed in Table 4 must be equal to
or greater than the standard established in Table 4 below.  The
standards listed in Table 4 below are based on utilization data for regions and
have been adjusted to accommodate estimated differences in utilization for all
counties in a region, including counties that did not have membership as of
February 1, 2006.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Table
4. Standards – Encounter Data Volume (Regional-Based Approach)

      
        	
                Region

              	
                Category

              	
                Measure
      per 1,000/MM

              	
                Standard
      for Dates of Service

                on
      or after 7/1/2007

              	
                Description

              
	
                Central

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                East
      Central

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                Northeast

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                Northeast
      Central

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              


      

       

      
        
          
             


          

          
            5

            
              

            

          

          
            
              Appendix
L

              Covered
Families and Children (CFC)
population   

            

          

        

      

       

      
        	
                Region

              	
                Category

              	
                Measure
      per 1,000/MM

              	
                Standard
      for Dates of Service

                on
      or after 7/1/2007

              	
                Description

              
	
                North-west

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                Southeast

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                South-west

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              
	
                West
      Central

              	
                Inpatient
      Hospital

              	
                Discharges

              	
                TBD

              	
                General/acute
      care, excluding newborns and mental health and chemical dependency
      services

              
	
                Emergency
      Department

              	
                 

                 

                 

                Visits

              	
                TBD

              	
                Includes
      physician and hospital emergency department encounters

              
	
                Dental

              	
                TBD

              	
                Non-institutional
      and hospital dental visits

              
	
                Vision

              	
                TBD

              	
                Non-institutional
      and hospital outpatient optometry and ophthalmology
  visits

              
	
                Primary
      & Specialist Care

              	
                TBD

              	
                Physician/practitioner
      and hospital outpatient visits

              
	
                Ancillary
      Services

              	
                TBD

              	
                Ancillary
      visits

              
	
                Behavioral
      Health

              	
                Service

              	
                TBD

              	
                Inpatient
      and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                TBD

              	
                Prescribed
      drugs

              


      

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population 


          

        

      

       

      Determination of Compliance:
Performance is monitored once every quarter for the entire report
period.  If the standard is not met for every service category in all
quarters of the report period in either the county-based, interim
regional-based, or regional-based approach, then the MCP will be determined to
be noncompliant for the report period.

      


      Penalty for
noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6.) of two
percent of the current month’s premium payment.  Monetary sanctions
will not be levied for consecutive quarters that an MCP is determined to be
noncompliant.  If an MCP is noncompliant for three consecutive
quarters, membership will be frozen. Once the MCP is determined to be compliant
with the standard and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.

      


      1.a.ii.       Incomplete
Outpatient Hospital Data

      


      Since
July 1, 1997, MCPs have been required to provide both the revenue code and the
HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain  a revenue code and CPT/HCPCS code. A CPT/HCPCS code must
accompany certain revenue center codes. These codes are listed in Appendix B of
Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness
measures.

      


      Measure: The percentage of
outpatient hospital line items with certain revenue center codes, as explained
above, which had an accompanying valid procedure (CPT/HCPCS)
code.  The measure will be calculated per MCP.

      


      Report Period:  For
the SFY 2009 and SFY 2010 contract periods, performance will be evaluated
using the report periods listed in 1.a.i., Table 1.

      


      Data Quality Standard: The
data quality standard is a minimum rate of 95%.

      


      Determination of
Compliance:  Performance is monitored once every quarter for
all report periods. 

      


      For
quarterly reports that are issued on or after July 1, 2007, an MCP will be
determined to be noncompliant for the quarter if the standard is not met in any
report period and the initial instance of noncompliance in a report period is
determined on or after July 1, 2007.  An initial instance of
noncompliance means that the result for the applicable report period was in
compliance as determined in the prior quarterly report, or the instance of
noncompliance is the first determination for an MCP’s first quarter of
measurement.

       

      
        
          
          

        

        
          7

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Penalty for
noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.

      


      Upon all
subsequent quarterly measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6) of one percent of the current month’s premium
payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.

      


      1.a.iii.     
Incomplete Data For Last Menstrual Period

      


      As
outlined in ODJFS Encounter
Data Specifications, the last menstrual period (LMP) field is a required
encounter data field. It is discussed in Item 14 of the “HCFA 1500 Billing
Instructions.” The date of the LMP is essential for calculating the clinical
performance measures and allows the ODJFS to adjust performance expectations for
the length of a pregnancy.

      


      The
occurrence code and date fields on the UB-92, which are “optional” fields, can
also be used to submit the date of the LMP. These fields are described in Items
32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital”
and “Outpatient Hospital UB-92 Claim Form Instructions.”

       

      
        An
occurrence code value of  ‘10’ indicates that a LMP date
was  provided. The actual date of the LMP would be given in the
‘Occurrence Date’ field.

        Measure: The percentage of
recipients with a live birth during the report period where a “valid” LMP
date was given on one or more of the recipient’s perinatal claims. If the LMP
date is before the date of birth and there is a difference of between 119 and
315 days between the date the recipient gave birth and the LMP date, then the
LMP date will be considered a valid date.  The measure will be
calculated per MCP (i.e., to include the MCP’s service area for the
CFC.

        


        Report
Period:   For the SFY 2009 contract period, performance
will be evaluated using the January - December  2008 report
period.  For the SFY  2010 contract period, performance will
be evaluated using the January - December  2009 report
period.

        


        Data Quality Standard: The
data quality standard is a minimum rate of 80%.

        


        Penalty for
noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6.) of one
percent of the current month’s premium payment.  Once the MCP is
performing at standard levels and violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded.

         

      

      
      

      
        
          
             


          

          
            8

            
              

            

          

          
            
              Appendix
L

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      1.a.iv.
Rejected Encounters

      


      Encounters
submitted to ODJFS that are incomplete or inaccurate are rejected
and  reported back to the MCPs on the Exception Report.  If
an MCP does not resubmit rejected encounters, ODJFS’ encounter data set will be
incomplete.

      


      Measure 1 only applies to
MCPs that have had Medicaid membership for more than one
year.

      


      Measure 1:  The
percentage of encounters submitted to ODJFS that are rejected.  The
measure will be calculated per MCP.

      


      Report Period:  For
the SFY 2009 contract period, performance will be evaluated using the following
report periods July - September 2008; October - December 2008; January - March
2009; April – June  2009.  For the SFY 2010 contract period,
performance will be evaluated using the following report periods July -
September 2009; October - December  2009;  January -
March  2010;  April – June  2010.

      


      Data Quality Standard for measure
1:  Data Quality Standard 1 is a maximum encounter data
rejection rate of 10% for each file type in the ODJFS-specified medium per
format for encounters submitted in SFY 2004 and thereafter. The measure will be
calculated per MCP.

      


      Determination of
Compliance:  Performance is monitored once every quarter.
Compliance determination with the standard applies only to the quarter under
consideration and does not include performance in previous
quarters.

      


      Penalty for noncompliance with the
Data Quality Standard for measure 1:  The first time
an MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of one percent of the current month’s premium
payment.  The monetary sanction will be applied for each file type in
the ODJFS-specified medium per format that is determined to be out of
compliance.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.

      


      Measure 2 only applies to
MCPs that have had Medicaid membership for one year or less.

      


      Measure 2:  The
percentage of encounters submitted to ODJFS that are rejected. The measure will
be calculated per MCP.

      


      Report Period: The report
period for Measure 2 is monthly.  Results are calculated and
performance is monitored monthly. The first reporting month begins with the
third month of enrollment.

       

      
        
          
          

        

        
          9

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Data Quality Standard for measure
2:  The data quality standard is a maximum encounter data
rejection rate for each file type in the ODJFS-specified medium per format as
follows:

      


      Third through sixth months with
membership:  50%

      


      Seventh through twelfth month with
membership:  25%

      


      Files in
the ODJFS-specified medium per format that are totally rejected will not be
considered in the determination of noncompliance.

      


      Determination of
Compliance:  Performance is monitored once every
month.  Compliance determination with the standard applies only to the
month under consideration and does not include performance in previous
quarters.

      


      Penalty for Noncompliance with the
Data Quality Standard for measure 2:  If the MCP is determined
to be noncompliant for either standard, ODJFS will impose a monetary sanction of
one percent of the MCP’s current month’s premium payment.  The
monetary sanction will be applied for each file type in the ODJFS-specified
medium per format that is determined to be out of compliance.  The
monetary sanction will be applied only once per file type per compliance
determination period and will not exceed a total of two percent of the MCP’s
current month’s premium payment.  Once the MCP is performing at
standard levels and violations/deficiencies are resolved to the satisfaction of
ODJFS, the money will be refunded.  Special consideration will be made
for MCPs with less than 1,000 members.

       

      1.a.v.
Acceptance Rate

      


      This measure only applies to
MCPs that have had Medicaid membership for one year or less.

      


      Measure: The rate of
encounters that are submitted to ODJFS and accepted (accepted encounters per
1,000 member months).  The measure will be calculated per
MCP

      


      Report Period:  The
report period for this measure is monthly.  Results are calculated and
performance is monitored monthly. The first reporting month begins with the
third month of enrollment.

      


      Data Quality
Standard:  The data quality standard is a monthly minimum
accepted rate of encounters for each file type in the ODJFS-specified medium per
format as follows:

      


      Third
through sixth month with
membership:                     50
encounters per 1,000 MM for NCPDP

      65 encounters per 1,000 MM for
NSF

      20 encounters per 1,000 MM for
UB-92

      


      Seventh
through twelfth month of
membership:               
250 encounters per 1,000 MM for NCPDP

      350 encounters per 1,000 MM for
NSF

      100 encounters per 1,000 MM for
UB-92

       

      
        
          
          

        

        
          10

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Determination of
Compliance:  Performance is monitored once every month.
Compliance determination with the standard applies only to the month under
consideration and does not include performance in previous months.

      


      Penalty for
Noncompliance:  If the MCP is determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction of one percent of the
MCP’s current month’s premium payment.  The monetary sanction will be
applied for each file type in the ODJFS-specified medium per format that is
determined to be out of compliance. The monetary sanction will be applied only
once per file type per compliance determination period and will not exceed a
total of two percent of the MCP’s current month’s premium
payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.  Special consideration will be made for MCPs with
less than 1,000 members.

      


      1.b.        
  Encounter Data Accuracy

      


      As with
data completeness, MCPs are responsible for assuring the collection and
submission of accurate data to ODJFS.  Failure to do so jeopardizes
MCPs’ performance, credibility and, if not corrected, will be assumed to
indicate a failure in actual performance.

      


      1.b.i.    
    Encounter Data Accuracy Studies

      


      Measure 1:  The
focus of this accuracy study will be on delivery encounters.  Its
primary purpose will be to verify that MCPs submit encounter data accurately
and  to ensure only one payment is made per delivery.  The
rate of appropriate payments will be determined by comparing a sample of
delivery payments to the medical record.  The measure will be
calculated per MCP (i.e., to include the MCP’s entire service area for the
CFC membership.

      


      Report Period:  In
order to provide timely feedback on the accuracy rate of encounters, the report
period will be the most recent from when the measure is
initiated.  This measure is conducted annually.

      


      Medical
records retrieval from the provider and submittal to ODJFS or its designee is an
integral component of the validation process.  ODJFS has optimized the
sampling to minimize the number of records required.  This methodology
requires a high record submittal rate.  To aid MCPs in achieving a
high submittal rate, ODJFS will give at least an 8 week period to retrieve and
submit medical records as a part of the validation process.  A record
submittal rate will be calculated as a percentage of all records requested for
the study.

      


      Data Quality Standard 1 for Measure 1: For
results that are finalized during the contract year, the accuracy rate for
encounters generating delivery payments is 100%.

       

      
        
          
          

        

        
          11

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Penalty for noncompliance:
The MCP must participate in a detailed review of delivery payments made for
deliveries during the report period.  Any duplicate or unvalidated
delivery payments must be returned to ODJFS.

      


      Data Quality Standard 2 for Measure
1:  A minimum record submittal rate of 85%.

      


      Penalty for
noncompliance:  For all encounter data accuracy studies that
are completed during this contract period, if an MCP is noncompliant with the
standard, ODJFS will impose a non-refundable $10,000 monetary
sanction.

      


      Measure 2:  This
accuracy study will compare the accuracy and completeness of payment data stored
in  MCPs’ claims systems during the study period to payment data
submitted to and accepted by ODJFS. The measure will be calculated per
MCP.  

      


      Payment
information found in MCPs’ claims systems for paid claims that does not match
payment information found on a corresponding encounter will be counted as
omissions.

      


      Report Period:  In
order to provide timely feedback on the omission rate of encounters, the report
period will be the most recent from when the measure is
initiated.  This measure is conducted annually.

      


      Data Quality Standard for Measure 2:
  For SFY 2009 and SFY 2010, to be determined.

      


      Penalty for
Noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6) of one
percent of the current month’s premium payment.  Once the MCP is
performing at standard levels and violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded.

       

      1.b.ii.     
 Generic Provider Number Usage

      


      Measure 1: This measure is
the percentage of institutional (UB-92) and professional (NSF) encounters with
the generic provider number in the Medicaid Provider Number
field.  Providers submitting claims which do not have an MMIS provider
number in the Medicaid Provider Number field must be submitted to ODJFS with the
generic provider number (i.e. 9111115).  The measure will be
calculated per MCP. The report period for this measure is
quarterly.

      


      Report Period for Measure
1:  For the SFY 2009 and SFY 2010 contract periods, performance
will be evaluated using the report periods listed in 1.a.i., Table
1.

       

      
        
          
          

        

        
          12

          
            

          

        

        
          
            Appendix
L

            Covered
Families and Children (CFC) population

          

        

      

       

      Data Quality Standard for Measure
1: A maximum generic provider number usage rate of 10%.

      


      Determination of Compliance for
Measure 1: Performance is monitored once every quarter for all report
periods.  For quarterly reports that are issued on or after July 1,
2007, an MCP will be determined to be noncompliant for the quarter if the
standard is not met in any report period and the initial instance of
noncompliance in a report period is determined on or after July 1,
2007.  An initial instance of noncompliance means that the result for
the applicable report period was in compliance as determined in the prior
quarterly report, or the instance of noncompliance is the first determination
for an MCP’s first quarter of measurement.

      


      Penalty for noncompliance for
Measure 1:   The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.

      


      Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of three percent of the current month’s premium
payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.

      


      Measure 2: This measure is
the percentage of pharmacy encounters with the generic provider number in the
“Prescribing Provider ID” field.  Providers submitting claims which do
not have an MMIS provider number in the “Prescribing Provider ID” field must be
submitted to ODJFS with the generic provider number (i.e.
9111115).  The measure will be calculated per MCP.  The
report period for this measure is quarterly.

      


      Report Period for Measure
2:  For the SFY 2009 and SFY 2010 contract periods, performance
will be evaluated using the report periods listed in 1.a.i., Table
1.

      


      Data Quality Standard for Measure
2:  To be determined.

      


      Determination of Compliance for
Measure 2: Performance is monitored once every quarter for all report
periods on or after July 1, 2008.  An initial instance of
noncompliance means that the result for the applicable report period was in
compliance as determined in the prior quarterly report, or the instance of
noncompliance is the first determination for an MCP’s first quarter of
measurement.

      


      Penalty for noncompliance with
Measure 2 :   The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.

      


      Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of three percent of the current month’s premium
payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.

       

      
        
          
          

        

        
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      1.c.        
  Timely Submission of Encounter Data

      


      1.c.i.       
Timeliness

      


      ODJFS
recommends submitting encounters no later than thirty-five days after the end of
the month in which they were paid.  ODJFS does not monitor standards
specifically for timeliness, but the minimum claims volume (Section 1.a.i.) and
the rejected encounter (Section 1.a.v.) standards are based on encounters being
submitted within this time frame.

      


      1.c.ii.      
Submission of Encounter Data Files in the ODJFS-specified medium per
format

      


      Information
concerning the proper submission of encounter data may be obtained from the
ODJFS Encounter Data File and
Submission Specifications document.  The MCP must submit a
letter of certification, using the form required by ODJFS, with each encounter
data file in the ODJFS-specified medium per format.

      


      The
letter of certification must be signed by the MCP’s Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO or
CFO.

       

      
        	
                 
      2.           
      CASE MANAGEMENT DATA

              	
                 

              


      

      


      ODJFS
designed a case management system (CAMS) in order to monitor MCP compliance with
program requirements specified in Appendix G, Coverage and
Services.  Each MCP’s case management data submissions will be
assessed for completeness and accuracy.   The MCP is responsible
for submitting a  case management file every month.  Failure to
do so jeopardizes
the MCP’s ability to demonstrate compliance with CSHCN
requirements.   For detailed descriptions of the case management
measures below, see ODJFS
Methods for Case Management Data Quality Measures.

      


      2.a.         
Case Management System Data Accuracy

      


      2.a.i.       
Open Case Management Spans for Disenrolled Members (this measure will be discontinued
as of January 2008)

      


      Measure:  The
percentage of the MCP’s adult and children case management records in the
Screening, Assessment, and Case Management System that have open case management
date spans for members who have disenrolled from the MCP.

      


      Report Period: For the SFY
2008 contract period, July – September 2007, and October – December
2007.

       

      Statewide and
Regional Data Quality Standard:  A rate of open case management
spans for disenrolled members of no more than 1.0%.

       

      
        
          
          

        

        
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      For an MCP which had membership as
of February 1, 2006:  Performance will be evaluated using: 1)
region-based results for any active region in which all selected MCPs had at
least 10,000 members during each month of the entire report period; and/or 2)
the statewide result for all counties that were not included in the region-based
results, but in which the MCP had managed care membership as of February 1,
2006.

      


      For any MCP which did not have
membership as of February 1, 2006: Performance will
begin to be evaluated using region-based results for any active
region  in which all selected MCPs had at least 10,000 members during
each month of the entire report period.

      


      Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the
region.

      


      Penalty for
noncompliance:   If an MCP is noncompliant with the
standard, then the ODJFS will issue a Sanction Advisory informing the MCP that a
monetary sanction will be imposed if the MCP is noncompliant for any future
report periods.  Upon all subsequent semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half of one percent of the current
month’s premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.

      


      2.b.          
Timely Submission of Case Management Files

      


      Data Quality Submission
Requirement: The MCP must submit Case Management files on a monthly basis
according to the specifications established in ODJFS’ Case Management File and
Submission Specifications.

      


      Penalty for noncompliance:
See Appendix N, Compliance Assessment System,
for the penalty for noncompliance with this requirement.

      


      
        	
                3.             EXTERNAL
      QUALITY REVIEW DATA

              	
                 

              


      

      


      In
accordance with federal law and regulations, ODJFS is required to conduct an
independent quality review of contracting managed care plans.  OAC
rule 5101:3-26-07(C) requires MCPs  to submit data and information as
requested by ODJFS or its designee for the annual external quality
review.

      


      Two
information sources are integral to these studies: encounter data and medical
records. Because encounter data is used to draw samples for these studies,
quality must be sufficient to ensure valid sampling.

       

      An adequate number of medical records must then be retrieved from
providers and submitted to ODJFS or its designee in order to generalize results
to all applicable members.  To aid MCPs in achieving the required
medical record submittal rate, ODJFS will give at least an eight week period to
retrieve and submit medical records.

       

      
        
          
             


          

          
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      3.a.          
Independent External Quality Review

      


      Measure:  The
percentage of requested records for a study conducted by the External Quality
Review Organization (EQRO) that are submitted by the managed care
plan.

      


      Report Period:  The
report period is one year. Results are calculated and performance is monitored
annually.  Performance is measured with each review.

      


      Data Quality Standard: A
minimum record submittal rate of 85% for each clinical measure.

      


      Penalty for noncompliance for Data
Quality Standard:  For each study that is completed during this
contract period, if an MCP is noncompliant with the standard, ODJFS will impose
a non-refundable $10,000 monetary sanction.

      


      4.            
MEMBERS’ PCP DATA

      


      The
designated PCP is the provider who will manage and coordinate the overall
care for CFC members, including those who have case management
needs.  The MCP must submit  a Members’ Designated PCP file
every month.  Specialists may and should be identified as the PCP as
appropriate for the member’s condition per the specialty types specified for the
CFC population in ODJFS Member’s PCP Data File and
Submission Specifications; however, no CFC member may have more than one
PCP identified for a given month.

      


      4.a.          
Timely submission of Member’s PCP Data

      


      Data Quality Submission
Requirement:  The MCP must submit a Members’ Designated PCP
Data file on a monthly basis according to the specifications established in
ODJFS Member’s PCP Data File and Submission
Specifications.

      


      Penalty for
noncompliance:  See Appendix N, Compliance Assessment System,
for the penalty for noncompliance with this requirement.

       

      
        
          
          

        

        
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      4.b.         
Designated PCP for newly enrolled members (only applicable for report periods
prior to January 2008)

      


      Measure:  The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.

      


      Report
Periods:  For the SFY 2008 contract period, performance will be
evaluated using the July-September 2007, and October – December 2007 report
periods.

      


      Data Quality
Standard:  SFY 2007 will be informational only. A minimum rate
of 75% of new members with PCP designation by their effective date of enrollment
for quarter one and quarter two of SFY 2008.

      


      Statewide
Approach:  MCPs will be evaluated using a statewide result,
including all active regions and counties (Mahoning and Trumbull) in which an
MCP has CFC membership.

      


      Penalty for
noncompliance:  If an MCP is noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half of one percent the current
month’s premium payment.  Once the MCP is performing at standard
levels and violations/deficiencies are resolved to the satisfaction of ODJFS,
the money will be refunded.  As stipulated in OAC rule 5101:3-26-08.2,
each new member must have a designated primary care provider (PCP) prior to
their effective date of coverage.  Therefore, MCPs are subject to
additional corrective action measures under Appendix N, Compliance Assessment
System, for failure to meet this requirement.

       

      4.b.i.        Designated
PCP for newly enrolled members (only applicable for report periods
after December 2007)

      


      Measure:  The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.

      


      Statewide
Approach:  MCPs  will be evaluated using their
statewide result, including all active regions and counties (Mahoning and
Trumbull) in which an MCP has CFC membership.

      


      Report
Periods:  For the SFY 2009 contract period, performance will be
evaluated annually using CY 2008.  For the SFY 2010 contract period,
performance will be evaluated annually using CY 2009.

      


      Data
Quality Standards:  For SFY 2009, a minimum rate of 85% of new members
with PCP designation by their effective date of enrollment.  For SFY
2010, a minimum rate of 85% of new members with PCP designation by their
effective date of enrollment.

      


      Penalty for
noncompliance:  If an MCP is noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half of one percent the current
month’s premium payment.  Once the MCP is performing at standard
levels and violations/deficiencies are resolved to the satisfaction of ODJFS,
the money will be refunded.  As stipulated in OAC rule 5101:3-26-08.2,
each new member must have a designated primary care provider (PCP) prior to
their effective date of coverage.  Therefore, MCPs are subject to
additional corrective action measures under Appendix N, Compliance Assessment
System, for failure to meet this requirement.

       

      
        
          
          

        

        
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      5.            
APPEALS AND GRIEVANCES DATA

      
        


        Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity.  ODJFS
requires these submissions to be in an electronic data file format pursuant to
the Appeal File and Submission
Specifications and Grievance File and Submission
Specifications.

        


        The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date.

        


        These
data files must be submitted in the ODJFS-specified format and with the
ODJFS-specified filename in order to be successfully processed.

        


        Penalty for
noncompliance:  MCPs who fail to submit their monthly
electronic data files to the ODJFS by the specified due date or who fail to
resubmit, by no later than the end of that month, a file which meets the data
quality requirements will be subject to penalty as stipulated under the
Compliance Assessment System (Appendix N).

      

       

      6.            
NOTES

      


      
        	
                6.a.

              	
                Penalties, Including Monetary
      Sanctions, for Noncompliance

              


      

      


      Penalties
for noncompliance with standards outlined in this appendix, including monetary
sanctions, will be imposed as the results are finalized.  With the
exception of  Sections 1.a.i., 1.a.iii.,  1.a.v., 1.a.iv,
and 1.b.ii,  no monetary sanctions described in this appendix will be
imposed if the MCP is in its first contract year of Medicaid program
participation.  Notwithstanding the penalties specified in
this
Appendix, ODJFS reserves the right to apply the most appropriate penalty to the
area of deficiency identified when an MCP is determined to be noncompliant with
a standard.  Monetary penalties for noncompliance with any individual
measure,  as determined in this appendix,  shall not exceed
$300,000 during each evaluation period.

      


      
        
          
            Refundable
monetary sanctions will be based on the
premium payment in the month of  the cited deficiency and due within
30 days of notification by ODJFS to the MCP of the amount.

            


            Any
monies collected through the imposition of such a sanction will be returned to
the MCP (minus any applicable collection fees owed to the Attorney General’s
Office, if the MCP has been delinquent in submitting payment) after the MCP has
demonstrated full compliance with the particular program requirement and the
violations/deficiencies are resolved to the satisfaction of ODJFS.  If
an MCP does not comply within two years of the date of notification of
noncompliance, then the monies will not be refunded.

             

          

        

      

      
        
          
          

        

        
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        6.b.         
Combined Remedies

        


        If ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance.  The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly premium payment.

        


        6.c.         
Membership Freezes

        


        MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to a
membership freeze.

        


        6.d.          Reconsideration

        


        Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.

        


        6.e.         
Contract Termination, Nonrenewals, or Denials

        


        Upon
termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS.

      

      


      
        
          
             


          

          
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M

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      APPENDIX
M

      


      PERFORMANCE
EVALUATION

      CFC
ELIGIBLE POPULATION

      


      This
appendix establishes minimum performance standards for managed care plans (MCPs)
in key program areas.  The intent is to maintain accountability for
contract requirements.  Standards are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.  Performance will be evaluated in the categories of
Quality of Care, Access, Consumer Satisfaction, and Administrative
Capacity.  Each performance measure has an accompanying minimum
performance standard. MCPs with performance levels below the minimum performance
standards will be required to take corrective action.

      


      With the
statewide expansion of the Ohio Medicaid Managed Care Program for the Covered
Families and Children (CFC) population nearly complete, evaluation of
performance will transition to a statewide approach encompassing all members who
meet the criteria specified per the given methodology for each measure (i.e.,
measures will include members in any county who meet criteria per the given
methodology as opposed to only those members with managed care membership as of
February 1, 2006).

      


      The
statewide approach was implemented beginning January 1, 2008.  Unless
otherwise noted, performance measures and standards (see Sections 1, 2, 3 and 4
of this appendix) will be applicable for all counties in which the MCP has
membership as of February 1, 2006, until statewide measurement is
implemented.

      


      Selected
measures in this appendix will be used to determine pay-for-performance (P4P) as
specified in Appendix O, Pay
for Performance.

      


      1.              QUALITY
OF CARE

      


      1.a.          
Independent External Quality Review

      


      In
accordance with federal law and regulations, state Medicaid agencies must
annually provide for an external quality review of the quality outcomes and
timeliness of, and access to, services provided by Medicaid-contracting MCPs
[(42 CFR 438.204(d)].  The external review assists the state in
assuring MCP compliance with program requirements and facilitates the collection
of accurate and reliable information concerning MCP performance.

      


      Measure:  The
independent external quality review covers a review of clinical and non-clinical
performance as outlined in Appendix K.

      


      Report
Period:  Performance will be evaluated using the reviews conducted
during SFY 2008.

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
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M

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        Action
Required for Deficiencies:  For all reviews conducted during the
contract period, if the EQRO cites a deficiency in performance, the MCP will be
required to complete a Corrective Action Plan or Quality Improvement Directive
depending on the severity of the deficiency.

         

        Serious deficiencies may result in immediate termination or
non-renewal of the provider agreement.

         

      

      1.b.           Children
with Special Health Care Needs (CSHCN)

      


      In order
to ensure state compliance with  the provisions of 42 CFR 438.208, the
Bureau of Managed Health Care established Children with Special Health Care
Needs (CSHCN) basic program requirements in Appendix G, Coverage and
Services,  and corresponding minimum performance standards as
described below. The purpose of these measures is to provide appropriate and
targeted case management services to CSHCN.

      


      1.b.i.        
Case Management of Children (applicable to performance
evaluation through December 2007 and P4P through SFY 2009)

      


      Measure: The average monthly
case management rate for children under 21 years of age.

      


      Report Period: For the SFY
2008 contract period:  July – September 2007 and October – December
2007 (for evaluation); and April – June 2008 (for P4P) report periods. For the
SFY 2009 contract period: April – June 2009 (for P4P) report
periods.

      


      County-Based
Approach:  MCPs with managed care membership as of February 1,
2006 will be evaluated  using their county-based statewide result
until regional evaluation is implemented for the county’s applicable
region.  The county-based statewide result will include data for all
counties in which the MCP had membership as of February 1, 2006 that are not
included in any regional-based result.  Regional-based results will
not be used for evaluation until all selected MCPs in an active region have at
least 10,000 members during each month of the entire report
period.  Upon implementation of regional-based evaluation for a
particular county’s region, the county will be included in the MCP’s
regional-based result and will no longer be included in the MCP’s county-based
statewide result. [Example: The county-based statewide result for MCP AAA, which
has contracts in the Central and West Central regions, will include Franklin,
Pickaway, Montgomery, Greene and Clark counties (i.e., counties in which MCP AAA
had managed care membership as of February 1, 2006).  When
regional-based evaluation is implemented for the Central region, Franklin and
Pickaway counties, along with all other counties in the region, will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and
Clark counties will remain in the county-based statewide result for evaluation
of MCP AAA until the West Central regional-based approach is implemented.] The
last report period using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix O) is April-June
2009.  A detailed description of the of excellent and superior
standards associated with this measure for P4P determination for SFY 2008 and
SFY 2009 can be found in Appendix O, Section 1.b1 and Section 2.b1.

      


      Regional-Based
Approach:   MCPs will be evaluated by region, using
results for all counties included in the region.  Performance will
begin to be evaluated using regional-based results for any active region in
which all selected MCPs had at least 10,000 members during each month of the
entire report period.

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
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Families and Children (CFC)
population 

          

        

      

      
         

        County and
Regional-Based Minimum
Performance Standard: For the third and fourth quarters of SFY 2007,
a case management rate of 5.0%.  For the first and second quarters of
SFY 2008, a case management rate of 5.0%.

        


        Penalty for
Noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.  Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant.  If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will occur
as outlined in Appendix N of the Provider Agreement.  Once the MCP is
determined to be compliant with the standard and the violations/deficiencies are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned.

      

       

      
        1.b.ii.        Case
Management of Children (applicable to performance
evaluation as of  January, 2008 and P4P as of SFY
2010)

      

      


      Measure: The average monthly
case management rate for children under 21 years of age.

      


      Report Period: For the SFY
2008 contract period, January – March 2008, and April – June 2008 report
periods.  For the SFY 2009 contract period,  July –
September 2008, October – December 2008, January – March 2009, and April – June
2009 report periods. For the SFY 2010 contract period,  July –
September 2009, October – December 2009, January – March 2010, and April – June
2010 report periods.

      


      Regional-Based Statewide
Approach:  Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Mahoning and Trumbull)
in which the MCP has membership.

      


      Regional-Based Statewide
Target:  For the third and fourth quarters of SFY 2008, a case
management rate of 5.0%.  For SFY 2009, a case management rate of
5.0%.  For SFY 2010, a case management rate of 5.0%.

      


      Regional-Based Statewide Minimum
Performance Standard:  The level of improvement must result in
at least a 20% decrease in the difference between the target and the previous
report period’s results.

      


      Penalty for
Noncompliance:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.  Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant.  If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will occur
as outlined in Appendix N of the Provider Agreement.  Once the MCP is
determined to be compliant with the standard and the violations/deficiencies are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned.

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
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M

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Families and Children (CFC)
population 

          

        

      

       

      1.b.iii.     
Case Management of Children with an ODJFS-Mandated Condition (applicable to performance
evaluation through December 2007)

      


      Measure 1:  The
percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of  asthma that are case
managed.

      


      Measure 2:  The
percent of  children age 17 and under with a positive identification
through an ODJFS administrative review of data for the ODJFS-mandated case
management condition of teenage pregnancy
that are case managed.

      


      Measure 3:  The
percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/AIDS that are
case managed.

      


      Report Periods for Measures 1, 2,
and 3: For the SFY 2008 contract period, July – September 2007 and
October – December 2007 report periods.

      


      County-Based
Approach:  MCPs with managed care membership as of February 1,
2006 will be evaluated using their county-based statewide result until regional
evaluation is implemented for the county’s applicable region.  The
county-based statewide result will include data for all counties in which the
MCP had membership as of February 1, 2006 that are not included in any
regional-based result.  Regional-based results will not be used for
evaluation until all selected MCPs in an active region have at least 10,000
members during each month of the entire report period.  Upon
implementation of regional-based evaluation for a particular county’s region,
the county will be included in the MCP’s regional-based result and will no
longer be included in the MCP’s county-based statewide result. [Example: The
county-based statewide result for MCP AAA, which has contracts in the Central
and West Central regions, will include Franklin, Pickaway, Montgomery, Greene
and Clark counties (i.e., counties in which MCP AAA had managed care membership
as of February  1, 2006).  When regional-based evaluation is
implemented for the Central region, Franklin and Pickaway counties, along with
all other counties in the region, will then be included in the Central region
results for MCP AAA; Montgomery, Greene, and Clark counties will remain in the
county-based statewide result for evaluation of MCP AAA until the West Central
regional-based approach is implemented.]

      


      Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the
region.  Performance will begin to be evaluated using regional-based
results for any
active region in which all selected MCPs had at least 10,000 members during each
month of the entire report period.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
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M

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Families and Children (CFC)
population 

          

        

      

       

      County and Regional-Based
Minimum Performance
Standard for Measures 1 and 3: For the third and fourth quarters of SFY
2007, a case management rate of 70%.  For the first and second
quarters of SFY 2008, a case management rate of 70%.

      


      County
and Regional-Based Minimum Performance Standard for Measure 2: For the first and
second quarters of SFY 2008, a case management rate of 60%.

      


      Penalty for Noncompliance for
Measures 1 and 2:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.  Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant.  If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will occur
as outlined in Appendix N of the Provider Agreement.  Once the MCP is
determined to be compliant with the standard and the violations/deficiencies are
resolved to the satisfaction of ODJFS, the penalties
will be lifted, if applicable, and monetary sanctions will be
returned.  Note:  For the first reporting period during
which regional results are used to evaluate performance, measures 1, 2, and 3
are reporting-only measures.  For SFY 2008, measure 3 is a
reporting-only measure.

       

      1.b.iv.      
Case Management of Children with an ODJFS-Mandated Condition (applicable to performance
evaluation as of January 2008)

      
        


        Measure 1:  The
percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of  asthma that are case
managed.

        


        Measure 2:  The
percent of children under 21 years of age with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management
condition of HIV/AIDS that are case managed.

        


        Report Periods for Measures 1 and
2:   For the SFY 2008 contract period, January – March
2008, and April – June 2008 report periods.  For the SFY 2009 contract
period, July – September 2008, October – December 2008, January – March 2009,
and April – June 2009 report periods.  For the SFY 2010 contract
period, July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.

        


        Regional-Based Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions and counties (Mahoning and Trumbull) in which the MCP has
membership.

      

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

      
Regional-Based Statewide Target for
Measures 1 and 2:  For the third and fourth quarters of SFY
2008, a case management rate of 70.0%.  For SFY 2009, a case
management rate of 80.0%.  For SFY 2010, a case management rate of
80.0%.

      


      Regional-Based Statewide Minimum
Performance Standard for Measures 1 and  2:  The
level of improvement must result in at least a 20% decrease in the difference
between the target and the previous report period’s results.

      


      Penalty for Noncompliance for
Measure 1:  The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.  Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant.  If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will occur
as outlined in Appendix N of the Provider Agreement.  Once the MCP is
determined to be compliant with the standard and the violations/deficiencies are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned. For SFY 2008 and SFY 2009,
measure 2 is a reporting-only measure.

      


      1.c.          
Clinical Performance Measures

       

      MCP
performance will be assessed based on the analysis of submitted encounter data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment of
other indicators for performance improvement activities.  Performance
on multiple measures will be assessed and reported to the MCPs and others,
including Medicaid consumers.

       

      The clinical performance measures described below closely follow the
National Committee for Quality Assurance’s Healthcare Effectiveness Data and
Information Set (HEDIS).  Minor adjustments to HEDIS measures are
required to account for the differences between the commercial population and
the Medicaid population, such as shorter and interrupted enrollment periods.
NCQA may annually change its method for calculating a measure.  These
changes can make it difficult to evaluate whether improvement occurred from
a  prior year.  For this reason, ODJFS will use the same
methods to calculate the baseline results and the results for the period in
which the MCP is being held accountable.  For example, the same
methods were being used to calculate calendar year  2005 results (the
baseline period) and calendar year  2006 results.  The
methods will be updated and a new baseline will be created during 2007 for
calendar  year  2006 results.  These results will
then serve as the baseline to evaluate whether improvement occurred from
calendar  year 2006 to calendar year 2007. Clinical performance
measure results will be calculated after a sufficient amount of time has passed
after the end of the report period in order to allow for claims
runout.  For a comprehensive description of the clinical performance
measures below, see ODJFS
Methods for Clinical Performance Measures for the CFC Managed Care
Program.  Performance standards are subject to change based on
the revision or update of NCQA methods or other national standards, methods or
benchmarks.

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006.  For reporting period CY 2008, targets and
performance standards for Clinical Performance Measures in
this Appendix (1.c.i – 1.c.vii) will be applicable to all counties in
which MCPs had membership as of February 1, 2006.  The final reporting
year for the counties in which an MCP had membership as of February 1, 2006,
will be CY 2008.

      


      For any MCP which did not have
membership as of February 1,
2006:  Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Trumbull and Mahoning)
in which the MCP has membership.

      


      Regional-Based Statewide
Approach: MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has
membership.

      


      For
measures requiring one year of baseline data, ODJFS will use the first full
calendar year of data (CY 2007) from all MCPs serving CFC
membership.  CY 2008 will be the first reporting year that MCPs will
be held accountable to the statewide performance standards for one year
measures, and penalties will be applied for noncompliance.

      


      For
measures requiring two years of baseline data, ODJFS will use the first two full
calendar years of data (CY 2007 and CY 2008) from all MCPs serving CFC
membership to determine statewide minimum performance standards.  CY
2009 will be the first reporting year that MCPs will be held accountable to the
statewide performance standards for two year measures, and penalties will be
applied for noncompliance.

      


      Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims
runout.

      


      Report Period:  In
order to adhere to the statewide expansion timeline, reporting
periods.  For the SFY 2008 contract period, performance will be
evaluated using the January - December 2007 report period.  For the
SFY 2009 contract period, performance will be evaluated using the January -
December 2008 report period.  For the SFY 2010 contract period,
performance will be evaluated using the January – December 2009 report
period.

       

      
        1.c.i.        
Perinatal Care – Frequency of Ongoing Prenatal Care

        


        Measure:  The
percentage of enrolled women with a live birth during the year who received the
expected number of prenatal visits.  The number of observed versus
expected visits will be adjusted for length of enrollment.

        


        County-Based Statewide
Target:  At least 80.0%
of the eligible population must receive 81.0% or more of the expected number of
prenatal visits.

         

        
          
            
            

          

          
            7

            
              

            

          

          
            
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M

              Covered
Families and Children (CFC)
population 

            

          

        

         

        County-Based Statewide Minimum
Performance Standard:  The level of improvement must result in
at least a 10.0% decrease in the difference between the target and the previous
report period’s results. (For example, if last year’s results were 20.0%,
then the difference between the target and last year’s results is
60.0%.  In this example, the standard is an improvement in performance
of 10.0% of this difference or 6.0%. In this example, results of 26.0% or better
would be compliant with the standard.)

      

      


      Regional-Based Statewide
Target:  To be determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

      


      Action Required for
Noncompliance:  Beginning SFY 2009, if the standard is not
met and the results are below 44.0% (49.0% for SFY 2010), the MCP is required to
complete a Corrective Action Plan to address the area of
noncompliance.  If the standard is not met and the results are at or
above 44.0% (49.0% for SFY 2010), ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps
that the MCP must take to improve the results.

      


      1.c.ii.       
Perinatal Care - Initiation of Prenatal Care

      


      Measure:    The
percentage of enrolled women with a live birth during the year who had a
prenatal visit within 42 days of enrollment or by the end of the first trimester
for those women who enrolled in the MCP during the early stages of
pregnancy.

      


      County-Based Statewide Target:
At least 90.0% of the eligible population initiates prenatal care within
the specified time.

      


      County-Based Statewide Minimum Performance
Standard: The level of improvement must result in at least a 10.0%
decrease in the difference between the target and the previous year’s
results.

      


      Regional-Based Statewide
Target: To be determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

      


      Action Required for
Noncompliance:  Beginning SFY 2009,  if the standard is
not met and the results are below 74.0%(77.0% for SFY 2010), the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance. If
the standard is not met and the results are at or above 74.0% (77.0% for SFY
2010), ODJFS will issue a Quality Improvement Directive which will notify the
MCP of noncompliance and may outline the steps that the MCP must take to improve
the results.

       

      
        
          
          

        

        
          8

          
            

          

        

        
          
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M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      1.c.iii.      Perinatal
Care - Postpartum Care

      


      Measure:   The
percentage of women who delivered a live birth who had a postpartum visit on or
between 21 days and 56 days after delivery.

      


      County-Based Statewide Target: At least
80.0% of the eligible population must receive a postpartum visit.

      


      County-Based Statewide
Minimum Performance
Standard: The level of improvement must result in at least a 5.0%
decrease in the difference between the target and the previous year’s
results.

      


      Regional-Based Statewide
Target:  To be
determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

      


      Action Required for Noncompliance:
SFY 2009,  if the standard is not
met and the results are below 50.0% (54.0% for SFY 2010), the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 50.0% (54.0% for SFY 2010),
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.

      


      1.c.iv.      
Preventive Care for Children - Well-Child Visits

      


      Measure:  The
percentage of children who received the expected number of well-child visits
adjusted by age and enrollment. The expected number of visits is as
follows:

      


      Children
who turn 15 months old: six or more well-child visits.

      


      Children
who were 3, 4, 5, or 6, years old: one or more well-child visits.

      


      Children
who were 12 through 21 years old: one or more well-child visits.

      


      County-Based Statewide
Target:  At least 80.0% of the eligible children receive the
expected number of well-child visits.

      County-Based  Statewide
Minimum Performance Standard for Each of the Age Groups:  The
level of improvement must result in at least a 10.0% decrease in the difference
between the target and the previous year’s results.

      


      Regional-Based Statewide
Target:  To be
determined.

      


      Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be
determined.

       

      
        
          
          

        

        
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M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Action Required for Noncompliance
(15 month old age group):  Beginning SFY 2009,  if the
standard is not met and the results are below 42.0% (47.0% for SFY 2010), the
MCP is required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 42.0%
(47.0% for SFY 2010), ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

       

      Action Required
for Noncompliance (3-6 year
old age group):  Beginning SFY 2009,  if the
standard is not met and the results are below 57.0% (63.0% for SFY 2010), the
MCP is required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 57.0%
(63.0% for SFY 2010), ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

       

      Action Required for Noncompliance
(12-21 year old age group):  Beginning SFY 2009, if the
standard is not met and the results are below 33.0% (35.0% for SFY 2010), the
MCP is required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 33.0%
(35.0% for SFY 2010), ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

      


      1.c.v.        
Use of Appropriate Medications for People with Asthma

      


      Measure: The percentage of
members with persistent asthma who were enrolled for at least 11 months with the
plan during the year and who received prescribed medications acceptable as
primary therapy for long-term control of asthma.

      


      County-Based Statewide
Target: At least 95.0% of the eligible population must receive the
recommended medications.

      


      County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous year’s
results.

      


      Regional-Based Statewide
Target:  To be determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

       

      
        
          
          

        

        
          10

          
            

          

        

        
          
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M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      Action Required for
Noncompliance: Beginning SFY 2009,  if the standard is not
met and the results are below 84.0% (86.0% for SFY 2010), the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 84.0% (86.0% for SFY 2010),
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.

       

      1.c.vi.      
Annual Dental Visits

      


      Measure: The percentage of
enrolled members age 4 through 21 who were enrolled for at least 11 months with
the plan during the year and who had at least one dental visit during the
year.

      


      County-Based Statewide
Target: At least
60.0% of the eligible population receives a dental visit.

      


      County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous year’s
results.

       

      Regional-Based Statewide
Target:  To be
determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

      


      Action Required for
Noncompliance:  Beginning SFY 2009,  if the standard is
not met and the results are below 42.0% (43.0% for SFY 2010), the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 42.0%
(43.0% for SFY 2010), ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

       

      
        
          
          

        

        
          11

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      1.c.vii.     
Lead Screening (For 1
Year Olds and For 2 Year Olds)

      


      The final
report period for these measures is CY 2008.

      


      Measure: The percentage of
one and two year olds who received a blood lead screening by age
group.

      


      County-Based Statewide
Target: At least 80.0% of the eligible population receives a blood lead
screening.

      


      County-Based Statewide Minimum
Performance Standard for Each of the Age Groups: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.

      


      Regional-Based Statewide
Target:  To be determined.

      


      Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be
determined.

      


      Action Required for Noncompliance (1
year olds): Beginning SFY 2007,  if the standard is not met and
the results are below 45.0% the MCP is required to complete a Corrective Action
Plan to address the area of noncompliance. If the standard is not met and the
results are at or above 45.0%, ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that the
MCP must take to improve the results.

      


      Action Required for Noncompliance (2
year olds): Beginning SFY 2007, if the standard is not met and the
results are below  28.0% the MCP is required to complete a Corrective
Action Plan to address the area of noncompliance.  If the standard is
not met and the results are at or above 28.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.

       

      
        
          
             


          

          
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M

              Covered
Families and Children (CFC) population 


            

          

        

      

      


      1.c.viii.    
Lead Testing in Children

      


      The
initial report period for this measure is CY 2009 (SFY 2010).  This
measure will replace the

      Lead
Screening for 1 Year Olds and for 2 Year Olds the P4P for SFY 2010.

      


      Measure: The percentage of
children who have turned two years of age during the reporting year who have
received one lead test on or before their second birthday.

      


      Regional-Based Statewide
Target:  To be determined.

      


      Regional-Based Statewide Minimum
Performance Standard: To be determined.

      


      Action Required for Noncompliance:
Beginning SFY 2010,  if the standard is not met and the results
are below TBD% the MCP is required to complete a Corrective Action Plan to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

      


      2.             
ACCESS

      


      Performance
in the Access category will be determined by the following measures: Primary
Care Provider (PCP) Turnover, Children’s Access to Primary Care, Adults’ Access
to Preventive/Ambulatory Health Services, and Members’ Access to Designated
PCP.  For a comprehensive description of the access performance
measures below, see ODJFS
Methods for Access Performance Measures for the CFC Managed Care
Program.

      


      2.a.          
PCP Turnover

      


      A high
PCP turnover rate may affect continuity of care and may signal poor management
of providers.  However, some turnover may be expected when MCPs end
contracts with providers who are not adhering to the MCP’s standard of
care.  Therefore, this measure is used in conjunction with the
children and adult access measures to assess performance in the access
category.

      


      Measure: The percentage of
primary care providers affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the
year.

      


      For an MCP which had membership as
of February 1, 2006:
MCP performance will be evaluated using an MCP’s county-based statewide
result for the counties in which the MCP had membership as
of  February 1, 2006.  The minimum performance standard in
this Appendix (2.a)
will be applicable to the MCP’s county-based statewide result for the counties
in which the MCP had membership as of February 1, 2006.  The last
reporting year using  the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for performance
evaluation is CY 2007; the last reporting year using the MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006 for P4P (Appendix
O) is CY 2008.

       

      
        
          
          

        

        
          13

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

      


      For any MCP which did not have
membership as of February 1,
2006:  Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Mahoning and Trumbull)
in which the MCP has membership.

      


      Regional-Based Statewide
Approach:  MCPs will be evaluated statewide, using results for
all regions and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of data (CY 2007) from
all MCPs serving CFC membership as a baseline to determine a statewide minimum
performance standard.  CY 2008 will be the first reporting year that
MCPs will be held accountable to the statewide performance standard for
statewide reporting, and penalties will be applied for
noncompliance.

      


      Report Period: For the SFY
2008 contract period, performance will be evaluated using the January - December
2007 report period.  For the SFY 2009 contract period, performance
will be evaluated using the January - December 2008 report
period.  For the SFY 2010 contract period, performance will be
evaluated using the January - December 2008 report period.

      


      County-Based Statewide Minimum
Performance Standard:  A maximum PCP Turnover rate of
18.0%.

      Regional-Based Statewide Minimum
Performance Standard:  To be
determined.

      


      Action Required for
Noncompliance:  MCPs are required to perform a causal analysis
of the high PCP turnover rate and assess the impact on timely access to health
services, including continuity of care.  If access has been reduced or
coordination of care affected, then the MCP must develop and implement a
corrective action plan to address the findings. 

       

      2.b.i.        
Children’s Access to Primary Care (applicable to performance
evaluation through SFY 2010)

      


       This measure indicates
whether children aged 12 months to 11 years are accessing PCPs for sick or
well-child visits.

      


      Measure: The percentage of
members age 12 months to 11 years who had a visit with an MCP PCP-type
provider.

      


      For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006.  The minimum performance standard in this
Appendix (2.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The last reporting
year using the MCP’s county-based statewide result for the counties in which the
MCP had membership as of February 1, 2006 is CY 2008.

       

      
        
          
          

        

        
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M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      For any MCP which did not have
membership as of February 1, 2006:  Performance will be
evaluated using a regional-based statewide approach for all active regions and
counties (Mahoning and Trumbull) in which the MCP has membership.

       

      
        Regional-Based Statewide
Approach: MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership.
ODJFS will use the first two full calendar years of data (CY 2007 and CY
2008)  from all MCPs serving CFC membership as a
baseline  to determine a statewide minimum performance
standard.  CY 2009 will be the first reporting year that MCPs will be
held accountable to the statewide performance standard for statewide reporting,
and penalties will be applied for noncompliance.  Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims
runout.

        


        Report Period: For the SFY 2008
contract period, performance will be evaluated using the January - December 2007
report period.  For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period.  For the
SFY 2010 contract period, performance will be evaluated using the January –
December 2009 report period.

        


        County-Based Statewide Minimum Performance
Standards:

        CY 2007
report period – 71.0% of children must receive a visit

        CY 2008
report period – 74.0% of children must receive a visit

        


        Regional-Based
Statewide Minimum Performance Standards:

        CY 2009
report period – To be determined.

      

       

      2.b.ii.      
Children’s Access to Primary Care (applicable to performance
evaluation as of SFY 2011)

      


      This
measure indicates whether children aged 12 months to 19 years are accessing PCPs
for sick or well-child visits.

      


      Measure: The percentage of
members age 12 months to 19 years who had a visit with an MCP PCP-type
provider.

      


      Regional-Based Statewide
Approach: MCPs will be evaluated statewide, using results for all active
regions and counties in which the MCP has membership. ODJFS will use CY 2008 and
CY 2009  data from all MCPs serving CFC membership as a
baseline  to determine a statewide minimum performance
standard.  CY 2010  will be the first reporting year that
MCPs will be held accountable to the statewide performance standard for
statewide reporting, and penalties will be applied for
noncompliance.  Statewide performance measure results will be
calculated after a sufficient amount of time has passed after the end of the
report period in order to allow for claims run out.

      


      Report Period:   For the SFY
2011 contract period, performance will be evaluated using the January - December
2010 report period.

      


      Regional-Based Statewide Minimum
Performance Standards: CY 2010
report period – To be determined.

      


      Penalty for
Noncompliance:  If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.

       

      
        
          
          

        

        
          15

          
            

          

        

        
          
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            Covered
Families and Children (CFC)
population 

          

        

      

       

      2.c.          
Adults’ Access to Preventive/Ambulatory Health Services

      


      This
measure indicates whether adult members are accessing health
services.

      


      Measure: The percentage of
members age 20 and older who had an ambulatory or preventive-care
visit.

      


      For an MCP which had membership as
of February 1,
2006: MCP performance will be evaluated using an MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006.  The minimum performance standard in this Appendix (2.c) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The last reporting
year using the MCP’s county-based statewide result for the counties in which the
MCP had membership as of February 1, 2006 for performance evaluation is CY 2007;
the last reporting year using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix O) is CY 2008.

      


      For any MCP which did not have
membership as of February 1, 2006:  Performance will be
evaluated using a regional-based statewide approach for all active regions and
counties (Mahoning and Trumbull) in which the MCP has membership.

      


      Regional-Based Statewide
Approach:  MCPs will be evaluated statewide, using results for
all active regions and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of data (CY 2007) from
all MCPs serving CFC membership as a baseline to determine a statewide minimum
performance standard.  CY 2008 will be the first reporting year that
MCPs will be held accountable to the statewide performance standard for
statewide reporting, and penalties will be applied for
noncompliance.  Statewide performance measure results will be
calculated after a sufficient amount of time has passed after the end of the
report period in order to allow for claims runout.

      


      Report Period: For the SFY 2008
contract period, performance will be evaluated using the January - December 2007
report period.  For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period.  For the
SFY 2010 contract period, performance will be evaluated using the January -
December 2009 report period.

      


      County-Based Statewide Minimum
Performance Standards:

      CY 2007
report period – 63.0% of adults must receive a visit.

      CY 2008
report period – 63.0% of adults must receive a visit (P4P only).

      


      Regional-Based
Statewide Minimum Performance Standards:

      CY 2008
report period – To be determined. (Evaluation only)

      CY 2009
report period –To be determined

      
        


        Penalty for
Noncompliance:  If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.

      

       

      
        
          
             


          

          
            16

            
              

            

          

          
            
              Appendix
M

              Covered
Families and Children (CFC) population 


            

          

        

      

      
      

       

      2.d.          
Members’ Access to Designated PCP

      


      The MCP
must encourage and assist CFC members without a designated primary care provider
(PCP) to establish such a relationship, so that a designated PCP can coordinate
and manage a member’s health care needs.  This measure is to be used
to assess MCPs’ performance in the access category.

      


      Measure:  The
percentage of members who had a visit through members’ designated
PCPs.

      


      Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has
membership.  ODJFS will use the first full calendar year of data (CY
2007) from all MCPs serving CFC membership as a baseline to determine a
statewide minimum performance standard.  CY 2008 will be the first
reporting year that MCPs will be held accountable to the performance standard
and penalties will be applied for noncompliance.  Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims
runout.

      


      Report Period:  For
the SFY 2009 contract period, performance will be evaluated using the January -
December 2008 report period.  For the SFY 2010 contract period,
performance will be evaluated using the January - December 2009 report
period.

      


      Regional-Based
Statewide Minimum Performance Standard:

      CY 2008 –
To be determined.

      CY 2009 –
To be determined

      


      Penalty for
Noncompliance:   If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.

      


      3.             
CONSUMER SATISFACTION

      


      In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS conducts annual independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting
MCP performance overall and in the areas of access, quality of care, and member
services.  For SFY 2008, performance in this category will be
determined by the overall satisfaction score.  For a comprehensive
description of the Consumer Satisfaction performance measure below, see ODJFS Methods for the Consumer
Satisfaction Performance Measure for the CFC Program.

       

      
        
          
          

        

        
          17

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

      


      Measure: Overall Satisfaction with
MCP: The average rating of the respondents to the Consumer Satisfaction
Survey who were asked to rate their overall satisfaction with their
MCP.  The results of this measure are reported annually.

      


      For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006.  The minimum performance standard in this
Appendix (3.) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.   For performance
evaluation, the last year to use the county-based statewide approach for the
counties in which the MCP had membership as of February 1, 2006 will be SFY
2008, using CY 2008 data.  For P4P (Appendix O),  the
last year to use the county-based statewide approach for the counties in which
the MCP had membership as of February 1, 2006 will be SFY 2009, using CY 2009
data.

      


      For any MCP which did not have
membership as of February 1, 2006:  Performance will be
evaluated using a regional-based statewide approach for all active regions and
counties (Mahoning and Trumbull)  in which the MCP has
membership.

      


      Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has
membership.  ODJFS will use the first full calendar year of data (CY
2008 adult and child survey results) from all MCPs serving CFC membership as a
baseline to establish a measure and determine a minimum statewide performance
standard.  For performance evaluation, the first year to use the
statewide regional-based approach will be SFY 2009, using CY 2009
data.  For P4P  (Appendix O),  the first year to
use the statewide regional-based approach will be SFY 2010, using CY 2010
data.

      


      Report Period: For the SFY 2008
contract period, performance will be evaluated using the results from the CY
2008 consumer satisfaction survey.  For the SFY 2009 contract period,
performance will be evaluated using the results from the CY 2009 consumer
satisfaction survey.   For the SFY 2010 contract period,
performance will be evaluated using the results from the CY 2010 consumer
satisfaction survey.

      


      County-Based Statewide Minimum Performance
Standard:  An average score of no less than 7.0.

      


      Regional-Based
Statewide Minimum Performance Standard: TBD

      


      Penalty for
noncompliance:  If an MCP is determined noncompliant with the
Minimum Performance Standard, then the MCP must develop a corrective action plan
and provider agreement renewals may be affected.

       

      4.             
ADMINISTRATIVE CAPACITY

      


      The
ability of an MCP to meet administrative requirements has been found to be both
an indicator of current plan performance and a predictor of future
performance.  Deficiencies in administrative capacity make the
accurate assessment of performance in other categories difficult, with findings
uncertain.  Performance in this category will be determined by the
Compliance Assessment System,  and the emergency department diversion
program.  For a comprehensive description of the Administrative
Capacity performance measures below, see ODJFS Methods for the Administrative Capacity
Performance Measure for the CFC Managed Care Program.

       

      
        
          
          

        

        
          18

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      4.a.          
Compliance Assessment System

      


      Measure:  The
number of points accumulated during a rolling 12-month period through the Compliance Assessment
System.

      


      Report Period: For the SFY 2009
contract period, performance will be evaluated using a rolling 12-month report
period.

      


      Performance
Standard:  A maximum of 15 points

      


      Penalty for Noncompliance:
Penalties for points are established in Appendix N, Compliance Assessment
System.

      


      4.b.           Emergency
Department Diversion (applicable to performance
evaluation through  SFY  2008)

      


      Managed
care plans must provide access to services in a way that assures access to
primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services.  MCPs
are required to identify high utilizers of ED services and implement action
plans designed to minimize inappropriate ED utilization.

      


      Measure:  The
percentage of members who had four or more ED visits during the six month
reporting period.

      


      For an MCP which had membership as
of February 1,
2006: MCP performance will be evaluated using an MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006.  The minimum performance standard and the target in this
Appendix (4.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The last reporting
period using  the MCP’s county-based statewide result for the counties
in which the MCP had membership as of February 1, 2006 for performance
evaluation is July-December 2007; the last reporting period using the MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006 for P4P (Appendix O) is July-December
2006.

      


      Report Period:  For
the SFY 2008 contract period, a baseline level of performance will be set using
the January - June 2007 report period.  Results will be calculated for
the reporting period of July - December 2007 and compared to the baseline
results to determine if the minimum performance standard is met.

       

      
        
          
          

        

        
          19

          
            

          

        

        
          
            Appendix
M

            Covered
Families and Children (CFC)
population 

          

        

      

       

      County-Based  Statewide Target:
A maximum of  0.70% of the eligible population will have four
or more ED visits during the reporting period.

      


      County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the baseline period
results.

      


      Penalty for
Noncompliance:  If the standard is not met and the results are
above 1.1%, then the MCP must develop a corrective action plan, for which ODJFS
may direct the MCP to develop the components of their EDD program as specified
by ODJFS.  If the standard is not met and the results are at or below
1.1%, then the MCP must develop a Quality Improvement Directive.

      


      4.b.i.        
Emergency Department Diversion (applicable to performance
evaluation as of SFY 2009)

      


      Managed
care plans must provide access to services in a way that assures access to
primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services.  MCPs
are required to identify high utilizers of targeted ED services and implement
action plans designed to minimize inappropriate, preventable and/or primary care
sensitive ED utilization.

      


      Measure:  The
percentage of members who had a number to be determined or more targeted ED
visits during the twelve month reporting period.

      


      Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has
membership.  ODJFS will use the first  full calendar year of
data (CY 2007) from all MCPs serving CFC membership as the first baseline reporting year
for statewide reporting and  to determine a statewide minimum
performance standard and target.  CY 2008 will be the first reporting
year that MCPs will be held accountable to the performance standard and
penalties will be applied for noncompliance.

      


      Report Period: For the SFY
2009 contract period, January – December 2008.  For the SFY 2010
contract period, January – December 2008.

      


      Regional-Based Statewide Target:
A maximum number to be determined of the eligible population will have a
number to be determined or more targeted ED visits during the reporting
period.

      


      Regional-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
percent to be determined decrease in the difference between the target and the
baseline period results.

      


      Penalty for
Noncompliance:  If the standard is not met and the results are
above a percent to be determined, then the MCP must develop a corrective action
plan, for which ODJFS may direct the MCP to develop the components of their EDD
program as specified by ODJFS.  If the standard is not met and the
results are at or below a percent to be determined, then the MCP must develop a
Quality Improvement Directive.

      


      
        
          
             


          

          
            20

            
              

            

          

          
            
              Appendix
M

              Covered
Families and Children (CFC) population 


            

          

        

      

       

      5.              NOTES

      


      Given
that unforeseen circumstances (e.g., revision or update of applicable national
standards, methods or benchmarks, or issues related to program implementation)
may impact performance assessment as specified in Sections 1 through
4, ODJFS reserves the right to apply the most appropriate penalty to the
area of deficiency identified with any individual measure, notwithstanding the
penalties specified in this Appendix.

      


      5.a.           Report
Periods

      


      Unless
otherwise noted, the most recent report or study finalized prior to the end of
the contract period will be used in determining the MCP’s performance level for
that contract period.

      


      5.b.          
Monetary Sanctions

      


      Penalties
for noncompliance with individual standards in this appendix will be imposed as
the results are finalized. Penalties for noncompliance with individual standards
for each period of compliance, as determined in this appendix, will not exceed
$250,000.

      


      Refundable
monetary sanctions will be based on the capitation payment in the month of the
cited deficiency and due within 30 days of notification by ODJFS to the MCP of
the amount.  Any monies collected through the imposition of such a
sanction would be returned to the MCP (minus any applicable collection fees owed
to the Attorney General’s Office, if the MCP has been delinquent in submitting
payment) after they have demonstrated improved performance in accordance with
this appendix.  If an MCP does not comply within two years of the date
of notification of noncompliance, then the monies will not be
refunded.

      


      5.c.          
Combined Remedies

      


      If ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance.  The total fines assessed in any one month will not
exceed 15.0% of the MCP’s monthly capitation.

      


      5.d.          
Enrollment Freezes

      


      MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to
an enrollment freeze.

      


      5.e.          
Reconsideration

      


      Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.

       

      
        5.f.           
Contract Termination, Nonrenewals or Denials

        


        Upon
termination, nonrenewal or denial of an MCP contract, all monetary sanctions
collected under this appendix will be retained by ODJFS. The at-risk amount paid
to the MCP under the current provider agreement will be returned to ODJFS in
accordance with Appendix P, Terminations, of the provider
agreement.

      

       

      
        
          
             


          

          
            21

            
              

            

          

          
            
              Appendix
N

              Covered
Families and Children (CFC) population   


            

          

        

      

       

      APPENDIX
N

      


      COMPLIANCE
ASSESSMENT SYSTEM 

      CFC
ELIGIBLE POPULATION

      


      


      I.              General
Provisions of the Compliance Assessment System

      


      A. The
Compliance Assessment System (CAS) is designed to improve the quality of each
managed care plan’s (MCP’s) performance through actions taken by the Ohio
Department of Job and Family Services (ODJFS) to address identified failures to
meet program requirements.  This appendix applies to the MCP specified
in the baseline of this MCP Provider Agreement (hereinafter referred to as the
Agreement).

      


      B. The
CAS assesses progressive remedies with specified values (e.g., points, fines,
etc.) assigned for certain documented failures to satisfy the deliverables
required by Ohio Administrative Code (OAC) rule or the
Agreement.  Remedies are progressive based upon the severity of the
violation, or a repeated pattern of violations.  The CAS allows the
accumulated point total to reflect patterns of less serious violations as well
as less frequent, more serious violations.

      


      C. The
CAS focuses on clearly identifiable deliverables and sanctions/remedial actions
are only assessed in documented and verified instances of
noncompliance.  The CAS does not include categories which require
subjective assessments or which are not within the MCPs control.

      


      D. The
CAS does not replace ODJFS’ ability to require corrective action plans (CAPs)
and  program improvements, or to impose any of the sanctions specified
in OAC rule 5101:3-26-10, including the proposed termination, amendment, or
nonrenewal of the MCP’s Provider Agreement.

      


      E. As
stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes a
sanction, MCPs are required to initiate corrective action for any MCP program
violations or deficiencies as soon as they are identified by the MCP or
ODJFS.

      


      F. In
addition to the remedies imposed in Appendix N, remedies related to areas of
financial performance, data quality, and performance management may also be
imposed pursuant to Appendices J, L, and M respectively, of the
Agreement.

      


      G. If
ODJFS determines that an MCP has violated any of the requirements of sections
1903(m) or 1932 of the Social Security Act which are not specifically identified
within the CAS, ODJFS may, pursuant to the provisions of OAC rule
5101:3-26-10(A), notify the MCP’s members that they may terminate from the MCP
without cause and/or suspend any further new member selections.

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC) population

          

        

      

       

      
        H. For
purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
violation is considered the date on which the violation
occurred.  Therefore, program violations that technically reflect
noncompliance from the previous compliance term will be subject to remedial
action under CAS at the time that ODJFS first becomes aware of this
noncompliance.

        


        I. In
cases where an MCP contracted healthcare provider is found to have violated a
program requirement (e.g., failing to provide adequate contract termination
notice, marketing to potential members, inappropriate member billing, etc.),
ODJFS will not assess points if: (1) the MCP can document that they provided
sufficient notification/education to providers of applicable program
requirements and prohibited activities; and (2) the MCP takes immediate and
appropriate action to correct the problem and to ensure that it does not happen
again to the satisfaction of ODJFS.  Repeated incidents will be
reviewed to determine if the MCP has a systemic problem in this area, and if so,
sanctions/remedial actions may be assessed, as determined by ODJFS.

        


        J. All
notices of noncompliance will be issued in writing via email and facsimile to
the identified MCP contact.

      

      


      II.           
Types of Sanctions/Remedial Actions

      


      ODJFS may
impose the following types of sanctions/remedial actions, including, but not
limited to, the items listed below.  The following are examples of
program violations and their related penalties.  This list is not all
inclusive.  As with any instance of noncompliance, ODJFS retains the
right to use their sole discretion to determine the most appropriate penalty
based on the severity of the offense, pattern of repeated noncompliance, and
number of consumers affected.  Additionally, if an MCP has received
any previous written correspondence regarding their duties and obligations under
OAC rule or the Agreement, such notice may be taken into consideration when
determining penalties and/or remedial actions.

      


      A. Corrective Action Plans
(CAPs) – A CAP is a structured activity/process implemented by the MCP to
improve identified operational deficiencies.

      


      MCPs may
be required to develop CAPs for any instance of noncompliance, and CAPs are not
limited to actions taken in this Appendix.  All CAPs requiring ongoing
activity on the part of an MCP to ensure their compliance with a program
requirement remain in effect for twenty-four months.

      


      In
situations where ODJFS has already determined the specific action which must be
implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
CAP.

       

      In situations where a penalty is assessed for a violation an MCP has
previously been assessed a CAP (or any penalty or any other related written
correspondence), the MCP may be assessed escalating penalties.

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC) population

          

        

      

       

      B. Quality Improvement
Directives (QIDs) – A QID is a general instruction that directs the MCP
to implement a quality improvement initiative to improve identified
administrative or clinical deficiencies.  All QIDs remain in effect
for twelve months from the date of implementation.

      


      MCPs may be required to develop QIDs
for any instance of noncompliance.

      


      In
situations where ODJFS has already determined the specific action which must be
implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
QID.

      


      In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a QID (or any penalty or any other related written
correspondence), the MCP may be assessed escalating penalties.

       

      C. Points - Points
will accumulate over a rolling 12-month schedule.  Each month, points
that are more than 12-months old will expire.  Points will be tracked
and monitored separately for each Agreement the MCP concomitantly holds with the
BMHC, beginning with the commencement of this Agreement (i.e., the MCP will have
zero points at the onset of this Agreement).

      


      No points
will be assigned for any violation where an MCP is able to document that the
precipitating circumstances were completely beyond their control and could not
have been foreseen (e.g., a construction crew severs a phone line, a lightning
strike blows a computer system, etc.).

       

       C.1.5 Points -- Failures
to meet program requirements, including but not limited to, actions
which  could impair the member’s ability to obtain correct information regarding services
or which could impair a consumer’s or member’s rights, as determined by ODJFS,
will result in the assessment of 5 points.  Examples include, but are
not limited to, the following:


      
        	
                 
      

              	
                •

              	
                Violations
      which result in a member’s MCP selection or termination based on
      inaccurate provider panel information from the
  MCP.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to provide member materials to new members in a timely
    manner.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to comply with appeal, grievance, or state hearing
      requirements, including the failure to notify a member of their right to a
      state hearing when the MCP proposes to deny, reduce, suspend or terminate
      a Medicaid-covered service.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to staff 24-hour call-in system with appropriate trained medical
      personnel.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to meet the monthly call-center requirements for either the member
      services or the 24-hour call-in system
lines.

              


      

      
        	
                 
      

              	
                •

              	
                Provision
      of false, inaccurate or materially misleading information to health care
      providers, the MCP’s members, or any eligible
  individuals.

              


      

      
        	
                 
      

              	
                •

              	
                Use
      of unapproved marketing or member
materials.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to appropriately notify ODJFS or members of provider panel
      terminations.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to update website provider directories as
  required.

              


      

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

       

      C.2. 10 Points --
Failures to meet program requirements, including but not limited to, actions
which could affect the ability of the MCP to deliver or the consumer to access covered
services, as determined by ODJFS.  Examples include, but are not
limited to, the following:

      


      
        	
                 
      

              	
                •

              	
                Discrimination
      among members on the basis of their health status or need for health care
      services (this includes any practice that would reasonably be expected to
      encourage termination or discourage selection by individuals whose medical
      condition indicates probable need for substantial future medical
      services).

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to assist a member in accessing needed services in a timely manner after
      request from the member.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to provide medically-necessary Medicaid covered services to
      members.

              


      

      
        	
                 
      

              	
                •

              	
                Failure
      to process prior authorization requests within the prescribed time
      frames.

              


      

      


      D. Fines – Refundable
or nonrefundable fines may be assessed as a penalty separate to or in
combination with other sanctions/remedial actions.

      


      D.1. Unless otherwise
stated, all fines are nonrefundable.

      


      D.2. Pursuant to
procedures as established by ODJFS, refundable and nonrefundable monetary
sanctions/assurances must be remitted to ODJFS within thirty (30) days of
receipt of the invoice by the MCP.  In addition, per Ohio Revised Code
Section 131.02, payments not received within forty-five (45) days will be
certified to the Attorney General’s (AG’s) office. MCP payments certified to the
AG’s office will be assessed the appropriate collection fee by the AG’s
office.

      


      D.3. Monetary
sanctions/assurances imposed by ODJFS will be based on the most recent premium
payments.

      


      D.4. Any monies
collected through the imposition of a refundable fine will be returned to the
MCP (minus any applicable collection fees owed to the Attorney General’s Office
if the MCP has been delinquent in submitting payment) after they have
demonstrated full compliance, as determined by ODJFS, with the particular
program requirement.  If an MCP does not comply within one (1) year of
the date of notification of noncompliance involving issues of case management
and two (2) years of the date of notification of noncompliance in issues
involving encounter data, then the monies will not be refunded.

      


      D.5. MCPs are
required to submit a written request for refund to ODJFS at the time they
believe is appropriate before a refund of monies will be
considered.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

       

      E. Combined Remedies
- Notwithstanding any other action ODJFS may take under this Appendix, ODJFS may
impose a combined remedy which will address all areas of noncompliance if ODJFS
determines, in its sole discretion, that (1) one systemic problem is responsible
for multiple areas of noncompliance and/or (2) that there are a number of
repeated instances of noncompliance with the same program
requirement.

      


      F. Progressive
Remedies - Progressive remedies will be based on the number of points
accumulated at the time of the most recent incident.  Unless
specifically otherwise indicated in this appendix, all fines are
nonrefundable.  The designated fine amount will be assessed when the
number of accumulated points falls within the ranges specified
below:

       

      
        	
                 

              	0
      -15 Points	
                Corrective
      Action Plan (CAP)

              
	
                 

              	16-25
      Points	
                CAP
      + $5,000 fine

              
	
                 

              	26-50
      Points	
                CAP
      + $10,000 fine

              
	
                 

              	51-70
      Points	
                CAP
      + $20,000 fine

              
	
                 

              	71-100
      Points	
                CAP
      + $30,000 fine

              
	
                 

              	100+
      Points	
                Proposed
      Contract Termination

              


      

       

      G. New Member Selection
Freezes - Notwithstanding any other penalty or point assessment that
ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP from
receiving new membership through consumer initiated selection or the assignment
process if: (1) the MCP has accumulated a total of 51 or more points during a
rolling 12-month period; (2) or the MCP fails to fully implement a CAP within
the designated time frame; or  (3) circumstances exist which
potentially jeopardize the MCP’s members’ access to care.  [Examples
of circumstances that ODJFS may consider as jeopardizing member access to care
include:

      


      
        	
                 
      

              	
                -

              	
                the
      MCP has been found by ODJFS to be noncompliant with the prompt payment or
      the non-contracting provider payment requirements;

              


      

      


      
        	
                 
      

              	
                -

              	
                the
      MCP has been found by ODJFS to be noncompliant with the provider panel
      requirements specified in Appendix H of the
  Agreement;

              


      

      


      
        	
                 
      

              	
                -

              	
                the
      MCP’s refusal to comply with a program requirement after ODJFS has
      directed the MCP to comply with the specific program requirement;
      or

              


      

      


      
        	
                 
      

              	
                -

              	
                the
      MCP has received notice of proposed or implemented adverse action by the
      Ohio Department of Insurance.]

              


      

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

       

      Payments
provided for under the Agreement will be denied for new enrollees, when and for
so long as, payments for those enrollees are denied by CMS in accordance with
the requirements in 42 CFR 438.730.

      


      H. Reduction of Assignments
– ODJFS has sole discretion over how member auto-assignments are
made.  ODJFS may reduce the number of assignments an MCP receives to
assure program stability within a region or if ODJFS determines that the MCP
lacks sufficient capacity to meet the needs of the increased volume in
membership.  Examples of circumstances which ODJFS may determine
demonstrate a lack of sufficient capacity include, but are not limited to an
MCP’s failure to: maintain an adequate provider network; repeatedly provide new
member materials by the member’s effective date; meet the minimum call center
requirements; meet the minimum performance standards for identifying and
assessing children with special health care needs and members needing case
management services; and/or provide complete and accurate appeal/grievance,
member’s PCP and CAMS data files.

      


      I. Termination, Amendment,
or Nonrenewal of MCP Provider Agreement - ODJFS can at any time move to
terminate, amend or deny renewal of a provider agreement.  Upon
such

      termination,
nonrenewal, or denial of an MCP provider agreement, all previously collected
monetary sanctions will be retained by ODJFS.

       

      J. Specific Pre-Determined
Penalties

      


      I.1. Adequate
network-minimum provider panel requirements - Compliance with provider
panel requirements will be assessed quarterly.  Any deficiencies in
the MCP’s provider network as specified in Appendix H of the Agreement or by
ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
category (practitioners, PCP capacity, hospitals), for each county, and for each
population (e.g., ABD, CFC).  For example if the MCP did not meet the
following minimum panel requirements, the MCP would be assessed (1) a $3,000
nonrefundable fine for the failure to meet CFC panel requirements; and, (2) a
$1,000 nonrefundable fine for the failure to meet ABD panel
requirements).

       

      
        	
                 
      

              	
                ·

              	
                practitioner
      requirements in Franklin county for the CFC
  population

              


      

      
        	
                 
      

              	
                ·

              	
                practitioner
      requirements in Franklin county for the ABD
  population

              


      

      
        	
                 
      

              	
                ·

              	
                hospital
      requirements in Franklin county for the CFC
  population

              


      

      
        	
                 
      

              	
                ·

              	
                PCP
      capacity requirements in Fairfield county for the CFC
      population

              


      

       

      In
addition to the pre-determined penalties, ODJFS may assess additional penalties
pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access
issues are identified resulting from provider panel noncompliance.

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

       

      J.2. Geographic Information
System - Compliance with the Geographic Information System (GIS)
requirements will be assessed semi-annually.  Any failure to meet GIS
requirements as specified in Appendix H of the Agreement will result a $1,000
nonrefundable fine for each county and for each population (e.g., ABD, CFC,
etc.).  For example if the MCP did not meet GIS requirements in the
following counties, the MCP would be assessed (1) a nonrefundable $2,000 fine
for the failure to meet GIS requirements for the CFC population and (2) a $1,000
nonrefundable fine for the failure to meet GIS requirements for the ABD
population.

       

      
        	
                 
      

              	
                ·

              	
                GIS
      requirements in Franklin county for the CFC
  population

              


      

      
        	
                 
      

              	
                ·

              	
                GIS
      requirements in Fairfield county for the CFC
  population

              


      

      
        	
                 
      

              	
                ·

              	
                GIS
      requirements in Franklin county for the ABD
  population

              


      

      


      J.3. Late Submissions
- All required submissions/data and documentation requests must be received by
their specified deadline and must represent the MCP in an honest and forthright
manner.  Failure to provide ODJFS with a required submission or any
data/documentation requested by ODJFS will result in the assessment of a
nonrefundable fine of $100 per day, unless the MCP requests and is granted an
extension by ODJFS.  Assessments for late submissions will be done
monthly.  Examples of such program violations include, but are not
limited to:

      


      
        	
                 
      

              	
                ·

              	
                Late
      required submissions

              


      

      
        	
                 
      

              	
                o

              	
                Annual
      delegation assessments

              


      

      
        	
                 
      

              	
                o

              	
                Call
      center report

              


      

      
        	
                 
      

              	
                o

              	
                Franchise
      fee documentation

              


      

      
        	
                 
      

              	
                o

              	
                Reinsurance
      information  (e.g., prior approval of
  changes)

              


      

      
        	
                 
      

              	
                o

              	
                State
      hearing notifications

              


      

      
        	
                 
      

              	
                ·

              	
                Late
      required data submissions

              


      

      
        	
                 
      

              	
                o

              	
                Appeals
      and grievances, case management, or PCP
data

              


      

      
        	
                 
      

              	
                ·

              	
                Late
      required information requests

              


      

      
        	
                 
      

              	
                o

              	
                Automatic
      call distribution reports

              


      

      
        	
                 
      

              	
                o

              	
                Information/resolution
      regarding consumer or provider
complaint

              


      

      
        	
                 
      

              	
                o

              	
                Just
      cause or other coordination care request from
  ODJFS

              


      

      
        	
                 
      

              	
                o

              	
                Provider
      panel documentation

              


      

      
        	
                 
      

              	
                o

              	
                Failure
      to provide ODJFS with a required submission after ODJFS has notified the
      MCP that the prescribed deadline for that submission has
      passed

              


      

       

      
        
          
            
              
              

            

            
              7

              
                

              

            

            
              
                Appendix
N

                Covered
Families and Children (CFC) population   


              

            

          

           

          If an MCP
determines that they will be unable to meet a program deadline or
data/documentation submission deadline, the MCP must submit a written request to
its Contract Administrator for an extension of the deadline, as soon as
possible, but no later than 3 PM EST on the date of the deadline in question.
Extension requests should only be submitted in situations where unforeseeable
circumstances have occurred which make it impossible for the MCP to meet an
ODJFS-stipulated deadline and all such requests will be evaluated upon this
standard.  Only written approval as may be granted by ODJFS of a
deadline extension will preclude the assessment of compliance action for
untimely submissions.

        

         

        J.4. Noncompliance with
Claims Adjudication Requirements - If ODJFS finds that an MCP is unable
to (1) electronically accept and adjudicate claims to final status and/or (2)
notify providers of the status of their submitted claims, as stipulated in
Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction
of $20,000 per day for the period of noncompliance.

        


        If ODJFS
has identified specific instances where an MCP has failed to take the necessary
steps to comply with the requirements specified in Appendix C of the Agreement
for (1) failing to notify non-contracting providers of procedures for claims
submissions when requested and/or (2) failing to notify contracting and
non-contracting providers of the status of their submitted claims, the MCP will
be assessed 5 points per incident of noncompliance.

        


        J.5. Noncompliance with
Prompt Payment: - Noncompliance with the prompt pay requirements as
specified in Appendix J of the Agreement will result in progressive
penalties.  The first violation during a rolling 12-month period will
result in the submission of quarterly prompt pay and monthly status reports to
ODJFS until the next quarterly report is due.  The second
violation during a
rolling 12-month period will result in the submission of monthly status
reports


      

      and a
refundable fine equal to 5% of the MCP’s monthly premium payment or $300,000,
whichever is less.  The refundable fine will be applied in lieu of a
nonrefundable fine and the money will be refunded by ODJFS only after the MCP
complies with the required standards for two (2) consecutive
quarters.  Subsequent violations will result in an enrollment
freeze.

       

      If an MCP is found to have not been in compliance with the prompt pay
requirements for any time period for which a report and signed attestation have
been submitted representing the MCP as being in compliance, the MCP will be
subject to an enrollment freeze of not less than three (3) months
duration.

       

      
        
          
          

        

        
          8

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

       

      J.6. Noncompliance with
Franchise Fee Assessment Requirements - In accordance with ORC Section
5111.176, and in addition to the imposition of any other penalty, occurrence or
points under this Appendix, an MCP that does not pay the franchise permit fee in
full by the due date is subject to any or all of the following:

      


      
        	
                 
      

              	
                ·

              	
                A
      monetary penalty in the amount of $500 for each day any part of the fee
      remains unpaid, except the penalty will not exceed an amount equal to 5 %
      of the total fee that was due for the calendar quarter for which the
      penalty was imposed;

              


      

      


      
        	
                 
      

              	
                ·

              	
                Withholdings
      from future ODJFS capitation payments.  If an MCP fails to pay
      the full amount of its franchise fee when due, or the full amount of the
      imposed penalty, ODJFS may withhold an amount equal to the remaining
      amount due from any future ODJFS capitation payments. ODJFS will return
      all withheld capitation payments when the franchise fee amount has been
      paid in full;

              


      

      


      
        	
                 
      

              	
                ·

              	
                Proposed
      termination or non-renewal of the MCP’s Medicaid provider agreement may
      occur if the MCP:

              


      

      
        	
                 
      

              	
                a.

              	
                Fails
      to pay its franchise permit fee or fails to pay the fee
      promptly;

              


      

      
        	
                 
      

              	
                b.

              	
                Fails
      to pay a penalty imposed under this Appendix or fails to pay the penalty
      promptly;

              


      

      
        	
                 
      

              	
                c.

              	
                Fails
      to cooperate with an audit conducted in accordance with ORC Section
      5111.176.

              


      

       

      
        J.7. Noncompliance with
Clinical Laboratory Improvement Amendments - Noncompliance with CLIA
requirements as specified by ODJFS will result in the assessment of a
nonrefundable $1,000 fine for each violation.

        


        J.8. Noncompliance with
Abortion and Sterilization Payment - Noncompliance with abortion and
sterilization requirements as specified by ODJFS will result in the
assessment of a nonrefundable $2,000 fine for each documented
violation.  Additionally, MCPs must take all appropriate action to
correct each ODJFS-documented violation.

      

      


      J.9. Refusal to Comply with
Program Requirements - If ODJFS has instructed an MCP that they must
comply with a specific program requirement and the MCP refuses, such refusal
constitutes documentation that the MCP is no longer operating in the best
interests of the MCP’s members or the state of Ohio and ODJFS will move to
terminate or nonrenew the MCP’s provider agreement.

       

      
        
          
          

        

        
          9

          
            

          

        

        
          
            Appendix
N

            Covered
Families and Children (CFC)
population   

          

        

      

      
III.          
Request for
Reconsiderations

      


      MCPs may
request a reconsideration of remedial action taken under the CAS for penalties
that include points, fines, reductions in assignments and/or selection
freezes.  Requests for reconsideration must be submitted on the ODJFS
required form as follows:

      


      A. MCPs
notified of ODJFS’ imposition of remedial  action taken under the CAS
will have ten (10) working days from the date of receipt of the facsimile to
request reconsideration, although ODJFS will impose enrollment freezes based on
an access to care concern concurrent with initiating notification to the
MCP.  Any information that the MCP would like reviewed as part of the
reconsideration request must be submitted at the time of submission of the
reconsideration request, unless ODJFS extends the time frame in
writing.

      


      B. All
requests for reconsideration must be submitted by either facsimile transmission
or overnight mail to the Chief, Bureau of Managed Health Care, and received by
ODJFS by the tenth business day after receipt of the faxed notification of the
imposition of the remedial action by ODJFS.

      


      C. The
MCP will be responsible for verifying timely receipt of all reconsideration
requests.  All requests for reconsideration must explain in detail why
the specified remedial action should not be imposed.  The MCP’s
justification for reconsideration will be limited to a review of the written
material submitted by the MCP.  The Bureau Chief will review all
correspondence and materials related to the violation in question in making the
final reconsideration decision.

      


      D. Final
decisions or requests for additional information will be made by ODJFS within
ten (10) business days of receipt of the request for
reconsideration.

      


      E. If
additional information is requested by ODJFS, a final reconsideration decision
will be made within three (3) business days of the due date for the
submission.  Should ODJFS require additional time in rendering the
final reconsideration decision, the MCP will be notified of such in
writing.

       

      F. If a
reconsideration request is decided, in whole or in part, in favor of the MCP,
both the penalty
and the points associated with the incident, will be rescinded or reduced, in
the sole discretion of ODJFS.  The MCP may still be required to submit
a CAP if ODJFS, in its sole discretion, believes that a CAP is still warranted
under the circumstances.

       

      
        
          
             


          

          
            10

            
              

            

          

          
            
              Appendix
O

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      APPENDIX
O

      


      PAY-FOR
PERFORMANCE (P4P)

      CFC
ELIGIBLE POPULATION

      


      This
Appendix establishes P4P for managed care plans (MCPs) to improve performance in
specific areas important to the Medicaid MCP members.  P4P include the
at-risk amount included with the monthly premium payments (see Appendix F, Rate Chart), and possible
additional monetary rewards up to $250,000.

      


      To
qualify for consideration of any P4P, MCPs must meet minimum performance
standards established in Appendix M, Performance Evaluation on
selected measures, and achieve P4P standards established for selected Clinical
Performance Measures.  For qualifying MCPs, higher performance
standards for three measures must be reached to be awarded a portion of the
at-risk amount and any additional P4P (see Sections 1 and 2).  An
excellent and superior standard is set in this Appendix for each of the three
measures.  Qualifying MCPs will be awarded a portion of the at-risk
amount for each excellent standard met.  If an MCP meets all three
excellent and superior standards, they may be awarded additional P4P (see
Section 3).

      


      Prior to
the transition to a regional-based statewide P4P system (SFY 2006 through SFY
2009), the county-based statewide P4P system (sections 1 and 2 of this Appendix)
will apply to MCPs with membership as of February 1, 2006.  Only
counties with membership as of February 1, 2006 will be used to calculate
performance levels for the county-based statewide P4P system.

      


      1.            
SFY 2008 P4P

      


      1.a.     
    Qualifying Performance Levels

      


      To
qualify for consideration of the SFY 2008 P4P, an MCP’s performance level must
meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below.  A detailed description of the
methodologies for each measure can be found on the BMHC page of the ODJFS
website.

      


      Measures
for which the minimum performance standard for SFY 2008 established in Appendix
M, Performance
Evaluation, must be met to qualify for consideration of P4P are as
follows:

      


      1.  PCP
Turnover (Appendix M, Section 2.a.)

      


      Report Period: CY
2007

      


      2.
Children’s Access to Primary Care (Appendix M, Section 2.b.)

      


      Report Period: CY
2007

      


      3.  Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

       

                     
Report Period: CY 2007

                                                      

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      4.
Overall Satisfaction with MCP (Appendix M, Section 3.)

      


      Report Period: The most
recent consumer satisfaction survey completed prior to the end of SFY
2008.

      


      For each
clinical performance measure listed below, the MCP must meet the P4P standard to
be considered for SFY 2008 P4P.  The MCP meets the P4P standard if one
of two criteria are met.  The P4P standard is a performance level of
either:

      


      1) The
minimum performance standard established in Appendix M, Performance Evaluation, for
seven of the nine clinical performance measures listed below; or

      


      2) The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below.  The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.

       

      
        	
                 

                Clinical
      Performance Measure

              	
                Medicaid

                Benchmark

              
	
                1.
      Perinatal Care - Frequency of Ongoing Prenatal Care

              	
                42%

              
	
                2.
      Perinatal Care - Initiation of Prenatal Care

              	
                71%

              
	
                3.
      Perinatal Care - Postpartum Care

              	
                48%

              
	
                4.
      Well-Child Visits – Children who turn 15 months old

              	
                34%

              
	
                5.
      Well-Child Visits - 3, 4, 5, or 6, years old

                6.
      Well-Child Visits - 12 through 21 years old

                7.
      Use of Appropriate Medications for People with Asthma

                8.
      Annual Dental Visits

                9.
      Blood Lead – 1 year olds

              	
                50%

                30%

                83%

                40%

                45%

              


      

       

      1.b.         
Excellent and Superior Performance Levels

      


      For
qualifying MCPs as determined by Section 1.a., performance will be evaluated on
the measures below to determine the status of the at-risk amount or any
additional P4P that may be awarded.  Excellent and Superior standards
are set for the three measures described below.  The standards are
subject to change based on the revision or update of applicable national
standards, methods or benchmarks.

      


      A brief
description of these measures is provided in Appendix M, Performance
Evaluation.  A detailed description of the methodologies for
each measure can be found on the BMHC page of the ODJFS website.

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      1. Case
Management of Children (Appendix M, Section 1.b.i.)

      


      Report Period: April - June
2008

       

      
        Excellent Standard:
5.5%

        


        Superior Standard:
6.5%

      

       

      2. Use of
Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)

      


      Report Period: CY
2007

      


      Excellent Standard:
86%

      


      Superior Standard:
88%

       

      3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

      


      Report Period: CY
2007

      


      Excellent Standard:
76%

      


      Superior Standard:
84%

      


      1.c.         
Determining SFY 2008 P4P

      


      MCP’s
reaching the minimum performance standards described in Section 1.a. herein,
will be considered for P4P including retention of the at-risk amount and any
additional P4P.  For each Excellent standard established in Section
1.b. herein, that an MCP meets, one-third of the at-risk amount may be
retained.  For MCPs meeting all of the Excellent and Superior
standards established in Section 1.b. herein, additional P4P may be
awarded.  For MCPs receiving additional P4P, the amount in the P4P
fund (see Section 3.) will be divided equally, up to the maximum additional
amount, among all MCPs’ ABD and/or CFC programs receiving additional
P4P.  The maximum additional amount to be awarded per plan, per
program, per contract year is $250,000.  An MCP may receive up to
$500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
Performance Levels.

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      2.            
SFY 2009 P4P

      


      2.a.         Qualifying
Performance Levels

      


      To
qualify for consideration of the SFY 2009 P4P, an MCP’s performance level must
meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below.  A detailed description of the
methodologies for each measure can be found on the BMHC page of the ODJFS
website.

       

      Measures
for which the minimum performance standard for SFY 2009 established in Appendix
M, Performance
Evaluation, must be met to qualify for consideration of P4P are as
follows:

       

      1.  PCP
Turnover (Appendix M, Section 2.a.)

      


      Report Period: CY
2008

      


      2.
Children’s Access to Primary Care (Appendix M, Section 2.b.)

      


      Report Period: CY
2008

      


      3.  Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

      


      Report Period: CY
2008                                                      

      


      4.
Overall Satisfaction with MCP (Appendix M, Section 3.)

      


      Report Period: The most
recent consumer satisfaction survey completed prior to the end of SFY
2009.

      


      For each
clinical performance measure listed below, the MCP must meet the P4P standard to
be considered for SFY 2009 P4P.  The MCP meets the P4P standard if one
of two criteria is met.  The P4P standard is a performance level of
either:

      


      1) The
minimum performance standard established in Appendix M, Performance Evaluation, for
seven of the nine clinical performance measures listed below; or

      


      2) The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below.  The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.

       

      
        
          
          

        

        
          4

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      
        	
                 

                Clinical
      Performance Measure

              	
                                   
      Medicaid

                                  
      Benchmark

              	 
	
                1.
      Perinatal Care - Frequency of Ongoing Prenatal Care

              	
                                      
       44%

              	 
	
                2.
      Perinatal Care - Initiation of Prenatal Care

              	
                                       
      74%

              	 
	
                3.
      Perinatal Care - Postpartum Care

              	
                                       
      50%

              	 
	
                4.
      Well-Child Visits – Children who turn 15 months old

              	
                                       
      42%

              	 
	
                5.
      Well-Child Visits - 3, 4, 5, or 6, years old

                6.
      Well-Child Visits - 12 through 21 years old

                7.
      Use of Appropriate Medications for People with Asthma

                8.
      Annual Dental Visits

                9.
      Blood Lead – 1 year olds

              	
                                       
      57%

                                       
      33%

                                       
      84%

                                       
      42%

                                       
      45%

              	 


      

       

       

      
        2.b.         
Excellent and Superior Performance Levels

        


        For
qualifying MCPs as determined by Section 2.a., performance will be evaluated on
the measures below to determine the status of the at-risk amount or any
additional P4P that may be awarded.  Excellent and Superior standards
are set for the three measures described below.  The standards are
subject to change based on the revision or update of applicable national
standards, methods or benchmarks.

      

       

      A brief
description of these measures is provided in Appendix M, Performance
Evaluation.  A detailed description of the methodologies for
each measure can be found on the BMHC page of the ODJFS website.

      


      1. Case
Management of Children (Appendix M, Section 1.b.i.)

      


      Report Period: April - June
2009

      


      Excellent Standard: To be
determined.

      


      Superior Standard: To be
determined.

      


      2. Use of
Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)

      


      Report Period: CY
2008

      


      Excellent Standard: To be
determined.

      


      Superior Standard: To be
determined.

       

      3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

      


      Report Period: CY
2008

      


      Excellent Standard:
77%

      


      Superior Standard:
84%

       

      
        
          
          

        

        
          5

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      2.c.         
Determining SFY 2008 P4P

      


      MCP’s
reaching the minimum performance standards described in Section 2.a. herein,
will be considered for P4P including retention of the at-risk amount and any
additional P4P.  For each Excellent standard established in Section
2.b. herein, that an MCP meets, one-third of the at-risk amount may be
retained.  For MCPs meeting all of the Excellent and Superior
standards established in Section 2.b. herein, additional P4P may be
awarded.  For MCPs receiving additional P4P, the amount in the P4P
fund (see Section 3.) will be divided equally, up to the maximum additional
amount, among all MCPs’ ABD and/or CFC programs receiving additional
P4P.  The maximum additional amount to be awarded per plan, per
program, per contract year is $250,000.  An MCP may receive up to
$500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
Performance Levels.

       

      3.            
NOTES

      


      3.a.         
Transition from a county-based statewide to a regional-based statewide P4P
system.

      


      The
current county-based statewide P4P system will transition to a regional-based
statewide system as managed care expands statewide.  The
regional-based statewide approach will be fully phased in no later than SFY
2010.  The regional-based statewide P4P system will be modeled after
the county-based statewide system with adjustments to performance standards
where appropriate.

      


      3.a.i.       County-based
statewide P4P system

      


      For MCPs
in their first twenty-four months of Ohio Medicaid CFC Managed Care Program
participation, the status of the at-risk amount will not be determined because
compliance with many of the standards cannot be determined in an MCP’s first two
contract years (see Appendix F., Rate Chart). In addition,
MCPs in their first two contract years are not eligible for the additional P4P
amount awarded for superior performance.

      


      Starting
with the twenty-fifth month of participation in the program, a new MCP’s at-risk
amount will be included in the P4P system. The determination of the status of
this at-risk amount will be after at least three full calendar years of
membership as many of the performance standards require three full calendar
years to determine an MCP’s performance level.  Because of this
requirement, more than 12 months of at-risk dollars may be included in an MCP’s
first at-risk status determination depending on when an MCP starts with the
program relative to the calendar year.

      


      During
the transition to a regional-based statewide system (SFY 2006 through SFY 2009),
MCPs with membership as of  February 1, 2006 will continue in the
county-based statewide P4P system until the transition is
complete.  These MCPs will be put at-risk for a portion of the
premiums received for members in counties they are serving as of February 1,
2006.

       

      
        
          
          

        

        
          6

          
            

          

        

        
          
            Appendix
O

            Covered
Families and Children (CFC) population   


          

        

      

       

      3.a.ii.      Regional-based
statewide P4P system

      


      All MCPs
will be included in the regional-based statewide P4P system.  The
at-risk amount will be determined separately for each region an MCP
serves.

      


      The
status of the at-risk amount for counties not included in the county-based
statewide P4P system will not be determined for the first twenty-four months of
regional membership.  Starting with the twenty-fifth month of regional
membership, the MCP’s at-risk amount will be included in the P4P system. The
determination of the status of this at-risk amount will be after at least three
full calendar years of regional membership as many of the performance standards
require three full calendar years to determine an MCP’s performance level. Given
that statewide expansion was not complete by December 31, 2006, ODJFS may adjust
performance measure reporting periods based on the number of months an MCP has
had regional membership. Because of this requirement, more than 12 months of
at-risk dollars may be included in an MCP’s first regional at-risk status
determination depending on when regional membership starts relative to the
calendar year.  Regional premium payments for months prior to July
2009 for members in counties included in the county-based statewide P4P system
for the SFY 2009 P4P determination, will be excluded from the at-risk dollars
included in the first regional-based statewide P4P determination.

       

      3.b.         
Determination of at-risk amounts and additional P4P payments

      


      Given
that unforeseen circumstances (e.g., revision or update of applicable national
standards, methods or benchmarks, or issues related to program implementation)
may impact the determination of the status of an MCP’s at-risk amount and any
additional P4P payments,  ODJFS reserves the right to calculate an
MCP’s at-risk amount (the status of which is determined in accordance with this
appendix) using a lesser percentage than that established in Appendix F
(Regional Rates) and to award additional P4P in an amount lesser than that
established in this appendix.

      


      For MCPs
that have participated in the Ohio Medicaid Managed Care Program long enough to
calculate performance levels for all of the performance measures included in the
P4P system, determination of the status of an MCP’s at-risk amount will occur
within six months of the end

      of the
contract period.  Determination of additional P4P payments will be
made at the same time the status of an MCP’s at-risk amount is
determined.

      


      3.c.        
Contract Termination, Nonrenewals, or Denials

      


      Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount paid to
the MCP under the current provider agreement will be returned to
ODJFS  in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
of the provider agreement.

      


      Additionally,
in accordance with Article XI of the provider agreement, the return of the
at-risk amount paid to the MCP under the current provider agreement will be a
condition necessary for ODJFS’ approval of a provider agreement
assignment.

      


      3.d.         
Report Periods

      


      The
report period used in determining the MCP’s performance levels varies for each
measure depending on the frequency of the report and the data
source.  Unless otherwise noted, the most recent report or study
finalized prior to the end of the contract period will be used in determining
the MCP’s overall performance level for that contract period.

      


      
        
          
             


          

          
            7

            
              

            

          

          
            
              Appendix
P

              Covered
Families and Children (CFC) population   


            

          

        

      

      


      APPENDIX
P

      


      MCP
TERMINATIONS/NONRENEWALS/AMENDMENTS

      ABD
ELIGIBLE POPULATION

      


      Upon
termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s
provider agreement, all previously collected refundable monetary sanctions will
be retained by ODJFS.

      


      1
..            MCP-INITIATED
TERMINATIONS/NONRENEWALS

      


      If an MCP
provides notice of the termination/nonrenewal of their provider agreement to
ODJFS, pursuant to Article VIII of the agreement, the MCP will be required to
submit the following to ODJFS:

      
        	
                               
      a.  

              	
                Refundable
      Monetary Assurance and the At-Risk
Amount

              


      

      The MCP
will be required to submit a refundable monetary assurance. This monetary
assurance will be held by ODJFS until such time that the MCP has submitted all
outstanding monies owed, data files, and reports, including, but not limited to,
grievance, appeal, encounter and cost report data related to time periods through the
final date of service under the MCP’s provider agreement.  The
monetary assurance must be in an amount of either $50,000 or 5 % of the
capitation amount paid by ODJFS in the month the termination/nonrenewal notice
is issued, whichever is greater.

      


      The MCP
must also return to ODJFS the at-risk amount paid to the MCP under the current
provider agreement.  The amount to be returned will be based on actual
MCP membership for preceding months and estimated MCP membership through the end
date of the contract.  MCP membership for each month between the month
the termination/nonrenewal is issued and the end date of the provider agreement
will be estimated as the MCP membership for the month the termination/nonrenewal
is issued. Any over payment will be determined by comparing actual to estimated
MCP membership and will be returned to the MCP following the end date of the
provider agreement.

      


      The MCP
must remit the monetary assurance and the at-risk amount in the specified
amounts via separate electronic fund transfers (EFT) payable to Treasurer of State, State of
Ohio(ODJFS).  The MCP should contact their Contract
Administrator to verify the correct amounts required for the monetary assurance
and the at-risk amount and obtain an invoice number prior to submitting the
monetary assurance and the at-risk amount.  Information from the
invoices must be included with each EFT to ensure monies are deposited in the
appropriate ODJFS Fund account.  In addition, the MCP must send copies
of the EFT bank confirmations and copies of the invoices to their Contract
Administrator.

      


      If the
monetary assurance and the at-risk amount are not received as specified above,
ODJFS will withhold the MCP’s next month’s capitation payment until such time
that ODJFS receives documentation that the monetary assurance and the at-risk
amount are received by the Treasurer of State. If within one year of the date of
issuance of the invoice, an MCP does not submit all outstanding monies owed and
required submissions, including, but not limited to, grievance, appeal,
encounter and cost report data related to time periods through the final date of
service under the MCP’s provider agreement, the monetary assurance will not be
refunded to the MCP.

       

      
        
          
          

        

        
          1

          
            

          

        

        
          
            Appendix
P

            Covered
Families and Children (CFC)
population 

          

        

      

       

      b.       
    Data Files

                   
 In order
to assist members with continuity of care, the MCP must create data files to be
shared with each newly enrolling MCP.  The data files will be provided
in 

                    
a consistant format specified by ODJFS and may include information on the
following:  case management, prior authorizations, inpatient facility
stays, PCP 

                    
assignments, and
pregnant members.  The timeline for providing these files will be at
the discretion of ODJFS.  The terminating MCP will be responsible for
ensuring

                    
the accuracy and data
quality of the files.

       

      
        
          	
                   
      

                	
                  c.

                	
                  Notification

                


        

        
          	
                   
      

                	
                  i.

                	
                  Provider
      Notification

                


        

        The MCP
must notify contracted providers at least 55 days prior to the effective date of
termination.  The provider notification must be approved by ODJFS
prior to distribution.

        


        ii.           Member
Notification

        The MCP
must notify their members of the termination at least 45 days in advance of the
effective date of termination. The member notification must  be
approved by ODJFS prior to distribution.

         

        iii.           Prior
Authorization Re-Direction Notification

        The MCP
must create two notices to assist members and providers with prior authorization
requests received and/or approved during the last month of membership. The first
notice is for prior authorization requests for services to be provided after the
effective date of termination; this notice will direct members and providers to
contact the enrolling MCP.  The second notice is for prior
authorization requests for services to be provided before and after the
effective date of termination.  The MCP must utilize ODJFS model
language to create the notices and receive approval by ODJFS prior to
distribution.  The notices will be mailed to the provider and copied
to the member for all requests received during the last month of MCP
membership.

        
           

        

        2.            
ODJFS-INITIATED
TERMINATIONS

        


        If ODJFS
initiates the proposed termination, nonrenewal or amendment of an MCP’s
provider

        agreement  pursuant
to OAC rule 5101:3-26-10 and the MCP appeals that proposed action, the MCP’s
provider agreement will be extended through the issuance of an adjudication
order in the MCP’s
appeal under the R.C. Chapter 119.

      

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
            Appendix
P

            Covered
Families and Children (CFC)
population 

          

        

      

      
         

        During
this time, the MCP will continue to accrue points and be assessed penalties for
each

        subsequent
compliance assessment occurrence/violation under Appendix N of the provider
agreement.  If the MCP exceeds 69 points, each subsequent point
accrual will result in a $15,000 nonrefundable fine.

      

       

      Pursuant
to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination, nonrenewal,
denial or amendment of a provider agreement, ODJFS may notify the MCP's members
of this proposed action and inform the members of their right to immediately
terminate their membership with that MCP without cause.  If ODJFS has
proposed the termination, nonrenewal, denial or amendment of   a
provider agreement and access to medically-necessary covered services is
jeopardized, ODJFS may propose to terminate the membership of all of the MCP's
members.  The appeal process for reconsideration of the proposed
termination of members is as follows:

      


      
        	
                ·

              	
                All
      notifications of such a proposed MCP membership termination will be made
      by ODJFS via certified or overnight mail to the identified MCP
      Contact.

              


      

      


      
        	
                ·

              	
                MCPs
      notified by ODJFS of such a proposed MCP membership termination will have
      three working days from the date of receipt to request
      reconsideration.

              


      

      


      
        	
                ·

              	
                All
      reconsideration requests must be submitted by either facsimile
      transmission or overnight mail to the Deputy Director, Office of Ohio
      Health Plans, and received by 3PM Eastern Time (ET) on the third working
      day following receipt of the ODJFS notification of termination. The
      address and fax number to be used in making these requests will be
      specified in the ODJFS notification of termination
    document.

              


      

      


      
        	
                ·

              	
                The
      MCP will be responsible for verifying timely receipt of all
      reconsideration requests.  All requests must explain in detail
      why the proposed MCP membership termination is not
      justified.  The MCP’s justification for reconsideration will be
      limited to a review of the written material submitted by the
      MCP.

              


      

       

      
        	
                ·

              	
                A
      final decision or request for additional information will be made by the
      Deputy Director within three working days of receipt of the request for
      reconsideration.   Should the Deputy Director require
      additional time in rendering the final reconsideration decision, the MCP
      will be notified of such in
writing.

              


      

      


      
        	
                ·

              	
                The
      proposed MCP membership termination will not occur while an appeal is
      under review and pending the Deputy Director’s decision.  If the
      Deputy Director denies the appeal, the MCP membership termination will
      proceed at the first possible effective date.  The date may be
      retroactive if the ODJFS determines that it would be in the best interest
      of the members.

              


      

      


      
        
          
             


          

          
            3